Healthcare Provider Details

I. General information

NPI: 1962071258
Provider Name (Legal Business Name): SVC OF PORT JEFFERSON STATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 PATCHOGUE RD
PORT JEFFERSON STATION NY
11776
US

IV. Provider business mailing address

1224 OSTRANDER AVE
RIVERHEAD NY
11901-2109
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-4707
  • Fax: 631-727-2866
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: JEFFREY WILLIAMS JR.
Title or Position: OD, OWNER
Credential: OD
Phone: 631-727-2858