Provider Demographics
NPI:1366675621
Name:EVERGREEN OPTICAL
Entity Type:Organization
Organization Name:EVERGREEN OPTICAL
Other - Org Name:HANMI OPTICIANS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OK JA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-463-2500
Mailing Address - Street 1:3717 UNION ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5580
Mailing Address - Country:US
Mailing Address - Phone:718-463-2500
Mailing Address - Fax:
Practice Address - Street 1:3717 UNION ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5580
Practice Address - Country:US
Practice Address - Phone:718-463-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier