Provider Demographics
NPI:1053536292
Name:OPTICAL VISION
Entity type:Organization
Organization Name:OPTICAL VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOAQUIN
Authorized Official - Middle Name:ARMANDO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-330-0123
Mailing Address - Street 1:4414 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5004
Mailing Address - Country:US
Mailing Address - Phone:201-330-0123
Mailing Address - Fax:201-271-1630
Practice Address - Street 1:4414 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5004
Practice Address - Country:US
Practice Address - Phone:201-330-0123
Practice Address - Fax:201-271-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00153100156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3162401Medicaid