Provider Demographics
NPI:1225330095
Name:NORTH SHORE OPTOMETRIC GROUP, PC
Entity Type:Organization
Organization Name:NORTH SHORE OPTOMETRIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:LARINA
Authorized Official - Middle Name:RAQUEL
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-627-5656
Mailing Address - Street 1:1129 NORTHERN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3022
Mailing Address - Country:US
Mailing Address - Phone:516-627-5656
Mailing Address - Fax:516-627-5672
Practice Address - Street 1:1129 NORTHERN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3022
Practice Address - Country:US
Practice Address - Phone:516-627-5656
Practice Address - Fax:516-627-5672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty