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General NPI Number Information
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NPI Number | 1316136401
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Entity Type | Organization
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Legal Business Name | PAVONIA OPTICAL INC.
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 12/14/2007
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Provider Practice Location Address
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Address Line | 600 PAVONIA AVE 6TH FLOOR
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City | JERSEY CITY
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State | NJ
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Zip | 07306-2929
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Country | US
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Telephone | 201-963-9187
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Fax |
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Provider Business Mailing Address
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Address Line | 600 PAVONIA AVE 6TH FLOOR
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City | JERSEY CITY
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State | NJ
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Zip | 07306
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Country | US
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Telephone | 201-963-9187
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | GLENN LURIE
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Credential | OPHTHALMIC DISPENSER
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Telephone | 201-963-9187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 31TD00155100
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License Number State | NJ
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