Provider Demographics
NPI:1033371331
Name:OPTICAL BOUTIQUE LLC
Entity Type:Organization
Organization Name:OPTICAL BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUKYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-246-6895
Mailing Address - Street 1:1 SPRING STREET
Mailing Address - Street 2:UNIT 101
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-2036
Mailing Address - Country:US
Mailing Address - Phone:732-246-6895
Mailing Address - Fax:
Practice Address - Street 1:1 SPRING ST
Practice Address - Street 2:UNIT 101
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2276
Practice Address - Country:US
Practice Address - Phone:732-246-6895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00552600152W00000X
NJ31TD00317100156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0165441Medicaid