Provider Demographics
NPI:1265635932
Name:ELEGANT EYES, INC
Entity Type:Organization
Organization Name:ELEGANT EYES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:VENNETTA
Authorized Official - Last Name:SLAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-622-4492
Mailing Address - Street 1:875 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-2622
Mailing Address - Country:US
Mailing Address - Phone:973-622-4492
Mailing Address - Fax:973-622-5919
Practice Address - Street 1:875 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2622
Practice Address - Country:US
Practice Address - Phone:973-622-4492
Practice Address - Fax:973-622-5919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD1360156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3349403Medicaid
NJ6609780001Medicare NSC