Provider Demographics
NPI:1992984504
Name:CUSTOM EYES INC.
Entity type:Organization
Organization Name:CUSTOM EYES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-736-8969
Mailing Address - Street 1:349 INDEPENDANCE PLAZA
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784
Mailing Address - Country:US
Mailing Address - Phone:631-736-8969
Mailing Address - Fax:
Practice Address - Street 1:349 INDEPENDANCE PLAZA
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784
Practice Address - Country:US
Practice Address - Phone:631-736-8969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service