Healthcare Provider Details

I. General information

NPI: 1346408416
Provider Name (Legal Business Name): OPTICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 MONTAUK HWY
COPIAGUE NY
11726-4901
US

IV. Provider business mailing address

940 MONTAUK HWY
COPIAGUE NY
11726-4901
US

V. Phone/Fax

Practice location:
  • Phone: 631-789-2525
  • Fax: 631-789-1495
Mailing address:
  • Phone: 631-789-2525
  • Fax: 631-789-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005528
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number003867-1
License Number StateNY

VIII. Authorized Official

Name: MR. THOMAS POLIZZI
Title or Position: OWNER
Credential: OPTICIAN
Phone: 631-789-2525