Provider Demographics
NPI:1407033947
Name:SUSAN VALENZA OPTICIAN, INC
Entity Type:Organization
Organization Name:SUSAN VALENZA OPTICIAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZA
Authorized Official - Suffix:
Authorized Official - Credentials:DISPENSING OPTICIAN
Authorized Official - Phone:973-667-0444
Mailing Address - Street 1:148 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2925
Mailing Address - Country:US
Mailing Address - Phone:973-667-0444
Mailing Address - Fax:976-667-2353
Practice Address - Street 1:148 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2925
Practice Address - Country:US
Practice Address - Phone:973-667-0444
Practice Address - Fax:976-667-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00091000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2903008Medicaid
NJ0662780001Medicare NSC