Provider Demographics
NPI:1538641444
Name:SHINE OPTIQUE
Entity Type:Organization
Organization Name:SHINE OPTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINGQIANG
Authorized Official - Middle Name:
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-804-8805
Mailing Address - Street 1:291 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4225
Mailing Address - Country:US
Mailing Address - Phone:718-218-8866
Mailing Address - Fax:718-218-8869
Practice Address - Street 1:291 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4225
Practice Address - Country:US
Practice Address - Phone:718-218-8866
Practice Address - Fax:718-218-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007790305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007790OtherOPTHALMIC DISPENSING LICENSE