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General NPI Number Information
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NPI Number | 1174731129
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Entity Type | Organization
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Legal Business Name | THE OPTICAL SOURCE
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1744 VETERANS MEMORIAL HIGHWAY
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City | ISLANDIA
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State | NY
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Zip | 11749
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Country | US
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Telephone | 631-348-4545
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Fax | 631-348-7299
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Provider Business Mailing Address
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Address Line | 1744 VETERANS MEMORIAL HIGHWAY
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City | ISLANDIA
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State | NY
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Zip | 11749
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Country | US
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Telephone | 631-348-4545
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Fax | 631-348-7299
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. ERNIE ALAN ROSEN
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Credential | DO
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Telephone | 631-348-4545
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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 | 0004616
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License Number State | NY
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