=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215113204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTI-TECH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2008
-----------------------------------------------------
Last Update Date | 01/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 E 14TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-979-4630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 CLIFTON AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-2642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | LUIS MENDOZA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-473-5151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------