Provider Demographics
NPI:1194109678
Name:OPTICAL OUTLET LLC
Entity type:Organization
Organization Name:OPTICAL OUTLET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AYBEE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-684-8400
Mailing Address - Street 1:1430 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2146
Practice Address - Country:US
Practice Address - Phone:973-684-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00660600152W00000X
NY56008349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty