MEDICARE: OPTICAL BOUTIQUE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	270A00552600	NJ
2	156FX1800X	Optician	31TD00317100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033371331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL BOUTIQUE LLC

Provider Business Mailing Address
First Line	:	1 SPRING STREET
Second Line	:	UNIT 101
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-2036
Country	:	US
Telephone Number	:	732-246-6895
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 SPRING ST
Second Line	:	UNIT 101
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-2276
Country	:	US
Telephone Number	:	732-246-6895
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN/OWNER
Name	:	MS. KARINA MANUKYAN
Credential	:
Telephone Number	:	732-246-6895

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	02/07/2014

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Directions to “OPTICAL BOUTIQUE LLC ” Practice Location

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