Provider Demographics
NPI:1659571206
Name:GLENRIDGE OPTICAL
Entity Type:Organization
Organization Name:GLENRIDGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:POST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-465-4999
Mailing Address - Street 1:8787 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2867
Mailing Address - Country:US
Mailing Address - Phone:718-465-4999
Mailing Address - Fax:718-217-6101
Practice Address - Street 1:8787 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2867
Practice Address - Country:US
Practice Address - Phone:718-465-4999
Practice Address - Fax:718-217-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007032332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02826460Medicaid
NY02826460Medicaid