Provider Demographics
NPI:1518169689
Name:COVENTRY OPTICAL, P.C.
Entity Type:Organization
Organization Name:COVENTRY OPTICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-454-4858
Mailing Address - Street 1:800 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1973
Mailing Address - Country:US
Mailing Address - Phone:908-454-4858
Mailing Address - Fax:908-859-2042
Practice Address - Street 1:800 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1973
Practice Address - Country:US
Practice Address - Phone:908-454-4858
Practice Address - Fax:908-859-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00374600156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1203180001Medicare NSC