Provider Demographics
NPI:1891238341
Name:JDN VISTA LLC
Entity Type:Organization
Organization Name:JDN VISTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-500-3962
Mailing Address - Street 1:28 VILLAGE GRN
Mailing Address - Street 2:APT E
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-1328
Mailing Address - Country:US
Mailing Address - Phone:914-500-3962
Mailing Address - Fax:
Practice Address - Street 1:200 PROMENADE BLVD
Practice Address - Street 2:TARGET OPTICAL
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3456
Practice Address - Country:US
Practice Address - Phone:732-357-1168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA006547OO152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty