Provider Demographics
NPI:1619411972
Name:SVC OF CORAM LLC
Entity type:Organization
Organization Name:SVC OF CORAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:631-727-7858
Mailing Address - Street 1:1224 OSTRANDER AVENUE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-727-2858
Mailing Address - Fax:631-727-2866
Practice Address - Street 1:1721 N OCEAN AVE STE A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2684
Practice Address - Country:US
Practice Address - Phone:631-732-0822
Practice Address - Fax:631-732-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty