Provider Demographics
NPI:1619531456
Name:ISLAND OPTICAL LLC
Entity Type:Organization
Organization Name:ISLAND OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSINOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-505-0533
Mailing Address - Street 1:275 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3554
Mailing Address - Country:US
Mailing Address - Phone:732-505-0533
Mailing Address - Fax:
Practice Address - Street 1:525 AVE FD ROOSEVELT
Practice Address - Street 2:PLAZA LAS AMERICAS SUITE 140
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-8020
Practice Address - Country:US
Practice Address - Phone:787-753-1033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty