=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336605344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALISADES OPTOMETRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2019
-----------------------------------------------------
Last Update Date | 06/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 348 BROAD AVE
-----------------------------------------------------
City | LEONIA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07605-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-429-9762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 E WASHINGTON ST STE 1100
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 92-228-2753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCESS MANAGER
-----------------------------------------------------
Name | TARA ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-322-6892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------