Healthcare Provider Details

I. General information

NPI: 1346441987
Provider Name (Legal Business Name): K&G OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 W PROSPECT ST
EAST BRUNSWICK NJ
08816-1911
US

IV. Provider business mailing address

1422 W PROSPECT ST
EAST BRUNSWICK NJ
08816-1911
US

V. Phone/Fax

Practice location:
  • Phone: 732-257-3755
  • Fax:
Mailing address:
  • Phone: 732-257-3755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberTD3443
License Number StateNJ

VIII. Authorized Official

Name: MRS. VESTA KIM
Title or Position: OWNER
Credential: OPTITION
Phone: 732-257-3755