Provider Demographics
NPI:1225234537
Name:BAYONNE WISE OPTICAL CENTER
Entity Type:Organization
Organization Name:BAYONNE WISE OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:VIRGILIO
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:201-823-3998
Mailing Address - Street 1:590 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3826
Mailing Address - Country:US
Mailing Address - Phone:201-823-3998
Mailing Address - Fax:201-823-2181
Practice Address - Street 1:590 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3826
Practice Address - Country:US
Practice Address - Phone:201-823-3998
Practice Address - Fax:201-823-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD3143261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ10454200001Medicare ID - Type UnspecifiedHEALTH INSURANCE