Healthcare Provider Details

I. General information

NPI: 1700017951
Provider Name (Legal Business Name): JERSEY GARDENS OPTICAL, LLL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 KAPKOWSKI RD SUITE 1236
ELIZABETH NJ
07201-4901
US

IV. Provider business mailing address

651 KAPKOWSKI RD SUITE 1236
ELIZABETH NJ
07201-4901
US

V. Phone/Fax

Practice location:
  • Phone: 908-354-1599
  • Fax: 908-354-1344
Mailing address:
  • Phone: 908-354-1599
  • Fax: 908-354-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number31TD00325201
License Number StateNJ

VIII. Authorized Official

Name: MR. YAN VAYNER
Title or Position: PRESIDENT/FRANCHISEE
Credential:
Phone: 908-354-1599