Healthcare Provider Details

I. General information

NPI: 1710421078
Provider Name (Legal Business Name): SVC OF SOUTHOLD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/03/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44210 RTE 48, STE. 1
SOUTHOLD NY
11971
US

IV. Provider business mailing address

1224 OSTRANDER AVENUE
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-3092
  • Fax: 631-765-3046
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 S SLANEY JR.
Title or Position: OWNER
Credential: OD
Phone: 631-727-7858