Healthcare Provider Details

I. General information

NPI: 1437290756
Provider Name (Legal Business Name): OPTICAL ILLUSIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 BROADWAY
THORNWOOD NY
10594-1139
US

IV. Provider business mailing address

3630 HILL BLVD, SUITE 203
JEFFERSON VALLEY NY
10535-1502
US

V. Phone/Fax

Practice location:
  • Phone: 914-741-2121
  • Fax: 914-741-5937
Mailing address:
  • Phone: 914-245-5151
  • Fax: 914-245-7157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND KOLKMANN
Title or Position: OWNER
Credential: OPTICIAN
Phone: 914-245-5151