Healthcare Provider Details

I. General information

NPI: 1154024768
Provider Name (Legal Business Name): SWDJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 DIVISION ST
NEW YORK NY
10002-6710
US

IV. Provider business mailing address

15 DIVISION ST
NEW YORK NY
10002-6710
US

V. Phone/Fax

Practice location:
  • Phone: 646-476-5210
  • Fax: 646-476-5207
Mailing address:
  • Phone: 646-476-5210
  • Fax: 646-476-5207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: DAWEI SUN
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential:
Phone: 646-476-5210