1801853254 NPI number — NORTHWEST OPTOMETRY GROUP, P.A.

Table of content: (NPI 1801853254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801853254 NPI number — NORTHWEST OPTOMETRY GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST OPTOMETRY GROUP, P.A.
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:
Provider Other Organization Name Type Code:
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:
1801853254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 SPARTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07871-1773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-729-9199
Provider Business Mailing Address Fax Number:
973-729-9260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 SPARTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07871-1773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-729-9199
Provider Business Practice Location Address Fax Number:
973-729-9260
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MULLIN
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
Authorized Official Title or Position:
V.P.
Authorized Official Telephone Number:
908-832-9211

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 331420102 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331420106 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331420104 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD9470 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 331420105 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331420103 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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