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General NPI Number Information
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NPI Number | 1700073012
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Entity Type | Organization
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Legal Business Name | THE OPTICAL ILLUSION
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Dates
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Enumeration Date | 10/01/2007
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 190 WESTWOOD AVE
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City | WESTWOOD
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State | NJ
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Zip | 07675-1741
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Country | US
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Telephone | 201-666-8705
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Fax |
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Provider Business Mailing Address
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Address Line | 190 WESTWOOD AVE
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City | WESTWOOD
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State | NJ
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Zip | 07675-1741
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Country | US
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Telephone | 201-666-8705
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CAROL REDDEN
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Credential |
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Telephone | 201-666-8705
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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 | D3239
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License Number State | NJ
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