Healthcare Provider Details

I. General information

NPI: 1366059172
Provider Name (Legal Business Name): SVC OF MANHASSET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 PLANDOME RD
MANHASSET NY
11030-1942
US

IV. Provider business mailing address

887 OLD COUNTRY RD STE GKL
RIVERHEAD NY
11901-2115
US

V. Phone/Fax

Practice location:
  • Phone: 516-627-0208
  • Fax: 516-627-2929
Mailing address:
  • Phone: 631-727-2858
  • Fax: 631-727-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY S WILLIAMS JR.
Title or Position: AUTHORIZED OFFICIAL / OWNER
Credential: OD
Phone: 631-422-2442