Healthcare Provider Details

I. General information

NPI: 1831708353
Provider Name (Legal Business Name): SVC OF MASTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 12/03/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 MONTAUK HWY
MASTIC NY
11950-2929
US

IV. Provider business mailing address

1224 OSTRANDER AVENUE
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-2858
  • Fax:
Mailing address:
  • Phone: 631-727-2858
  • Fax:

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: JEFFREY S WILLIAMS
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential: OD
Phone: 631-442-2442