Healthcare Provider Details

I. General information

NPI: 1376860601
Provider Name (Legal Business Name): ELEGANT OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W FRONT ST 114
PLAINFIELD NJ
07060-1107
US

IV. Provider business mailing address

211 W FRONT ST 114
PLAINFIELD NJ
07060-1107
US

V. Phone/Fax

Practice location:
  • Phone: 908-755-2500
  • Fax: 908-755-2507
Mailing address:
  • Phone: 908-755-2500
  • Fax: 908-755-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number3287
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: UTENZI MILLER-JOHNSON
Title or Position: OPTICIAN
Credential: DO
Phone: 908-755-2500