Provider Demographics
NPI:1992872675
Name:L&M OPTICAL INC
Entity type:Organization
Organization Name:L&M OPTICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEGIACOMO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:973-338-5620
Mailing Address - Street 1:1025 BROAD ST
Mailing Address - Street 2:VALENZA OPTICIANS
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2844
Mailing Address - Country:US
Mailing Address - Phone:973-338-5620
Mailing Address - Fax:973-338-6884
Practice Address - Street 1:1025 BROAD ST
Practice Address - Street 2:VALENZA OPTICIANS
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2844
Practice Address - Country:US
Practice Address - Phone:973-338-5620
Practice Address - Fax:973-338-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD1614332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ16213109Medicaid
NJ16213109Medicaid