Provider Demographics
NPI:1194912154
Name:PASSAIC VISION CENTER ,LLC.
Entity type:Organization
Organization Name:PASSAIC VISION CENTER ,LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-473-5151
Mailing Address - Street 1:PO BOX 1758
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07015-1758
Mailing Address - Country:US
Mailing Address - Phone:973-473-5151
Mailing Address - Fax:973-473-3331
Practice Address - Street 1:289 MONROE ST.
Practice Address - Street 2:PASSAIC VISION CENTER
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5209
Practice Address - Country:US
Practice Address - Phone:973-473-5151
Practice Address - Fax:973-473-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0054721Medicaid
NJ084669Medicare PIN
NJ0054721Medicaid