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General NPI Number Information
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NPI Number | 1033371331
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Entity Type | Organization
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Legal Business Name | OPTICAL BOUTIQUE LLC
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Dates
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Enumeration Date | 06/27/2008
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 1 SPRING ST UNIT 101
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City | NEW BRUNSWICK
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State | NJ
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Zip | 08901-2276
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Country | US
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Telephone | 732-246-6895
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Fax |
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Provider Business Mailing Address
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Address Line | 1 SPRING STREET UNIT 101
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City | NEW BRUNSWICK
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State | NJ
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Zip | 08901-2036
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Country | US
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Telephone | 732-246-6895
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Fax |
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Authorized Official
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Title or Position | OPTICIAN/OWNER
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Name | MS. KARINA MANUKYAN
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Credential |
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Telephone | 732-246-6895
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 270A00552600
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 31TD00317100
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License Number State | NJ
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