Individual
BERTA POLVANOVA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
9732 63RD RD, REGO PARK, NY 11374-1639
(718) 539-3646
Mailing address
69-23 168 STREET, FRESH MEADOWS, NY 11365
(718) 755-0656
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
008685-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03396027
—
NY
Enumeration date
12/10/2012
Last updated
12/10/2012
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