Provider Demographics
NPI:1972191666
Name:EYE HEALTH GROUP OF TR LLC
Entity type:Organization
Organization Name:EYE HEALTH GROUP OF TR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSINOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-537-9979
Mailing Address - Street 1:275 ROUTE 22 E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3554
Mailing Address - Country:US
Mailing Address - Phone:321-537-9979
Mailing Address - Fax:
Practice Address - Street 1:275 ROUTE 22 E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3554
Practice Address - Country:US
Practice Address - Phone:321-537-9979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty