Provider Demographics
NPI:1285047464
Name:OPTICAL OUTLET LLC
Entity type:Organization
Organization Name:OPTICAL OUTLET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:DR
Authorized Official - First Name:OPTICAL
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-298-1400
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:973-298-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization