Provider Demographics
NPI:1356952535
Name:MK EYECARE
Entity type:Organization
Organization Name:MK EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KALEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-575-8288
Mailing Address - Street 1:7010 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4552
Practice Address - Country:US
Practice Address - Phone:212-219-2219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03279398Medicaid