Provider Demographics
NPI:1790236735
Name:MAIN ST. OPTICAL LLC
Entity Type:Organization
Organization Name:MAIN ST. OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YASIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MASADEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-239-9550
Mailing Address - Street 1:1010 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2212
Practice Address - Country:US
Practice Address - Phone:862-239-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00615400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty