Provider Demographics
NPI:1548308430
Name:SOUTHERN VISION CARE PC.
Entity type:Organization
Organization Name:SOUTHERN VISION CARE PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LACORTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-924-2552
Mailing Address - Street 1:811 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-5202
Mailing Address - Country:US
Mailing Address - Phone:718-993-5466
Mailing Address - Fax:
Practice Address - Street 1:811 SOUTHERN BLVD LBBY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-5202
Practice Address - Country:US
Practice Address - Phone:718-924-2552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUV004778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01048159Medicaid
0485660001Medicare NSC
NYA100081307Medicare PIN
NY01048159Medicaid