Provider Demographics
NPI:1023184678
Name:OPTICAL PALACE OF PATERSON
Entity Type:Organization
Organization Name:OPTICAL PALACE OF PATERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAISHRI
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAITHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-881-1030
Mailing Address - Street 1:93 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1026
Mailing Address - Country:US
Mailing Address - Phone:973-881-1030
Mailing Address - Fax:973-881-1031
Practice Address - Street 1:93 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505-1026
Practice Address - Country:US
Practice Address - Phone:973-881-1030
Practice Address - Fax:973-881-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0105058Medicaid