1366547838 NPI number — SUPREME EYE CENTER INC

Table of content: (NPI 1366547838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366547838 NPI number — SUPREME EYE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPREME EYE CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STERLING OPTICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366547838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MOUNT HOPE AVE
Provider Second Line Business Mailing Address:
SUITE# 2043
Provider Business Mailing Address City Name:
ROCKAWAY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07866-2130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-366-3402
Provider Business Mailing Address Fax Number:
973-366-5072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MOUNT HOPE AVE
Provider Second Line Business Practice Location Address:
SUITE# 2043
Provider Business Practice Location Address City Name:
ROCKAWAY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07866-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-366-3402
Provider Business Practice Location Address Fax Number:
973-366-5072
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHOE
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
973-366-3402

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  27OA00595700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0050113 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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