Provider Demographics
NPI:1023041589
Name:SOUTH SHORE OPTICIANS INC
Entity Type:Organization
Organization Name:SOUTH SHORE OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARVEA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:516-825-8990
Mailing Address - Street 1:1033 GREEN ACRES MALL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:516-825-8990
Mailing Address - Fax:516-872-2702
Practice Address - Street 1:1033 GREEN ACRES MALL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581
Practice Address - Country:US
Practice Address - Phone:516-825-8990
Practice Address - Fax:516-872-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT024291152W00000X
NYTUV005493152W00000X
NY0043021156FX1800X
NY0037511156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01016646Medicaid
NY110439001Medicare ID - Type Unspecified