Provider Demographics
NPI:1992096150
Name:GRAND CONCOURSE BRONX EYE CARE INC
Entity type:Organization
Organization Name:GRAND CONCOURSE BRONX EYE CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVELENSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-365-6300
Mailing Address - Street 1:2376 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6907
Mailing Address - Country:US
Mailing Address - Phone:718-365-6300
Mailing Address - Fax:718-477-6702
Practice Address - Street 1:2376 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6907
Practice Address - Country:US
Practice Address - Phone:718-365-6300
Practice Address - Fax:718-477-6702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003094152W00000X
NYTUV007588332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100087888Medicare PIN