Healthcare Provider Details

I. General information

NPI: 1770747321
Provider Name (Legal Business Name): PT JEFF OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 ROUTE 112
PT JEFFERSON STATION NY
11776
US

IV. Provider business mailing address

1092 ROUTE 112
PT JEFFERSON STATION NY
11776
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-3937
  • Fax: 631-474-3966
Mailing address:
  • Phone: 631-474-3937
  • Fax: 631-474-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0081081
License Number StateNY

VIII. Authorized Official

Name: MR. LARRY P FRANKEL
Title or Position: PRESIDENT
Credential: OPTICIAN
Phone: 631-474-3937