Provider Demographics
NPI:1952835167
Name:EYE SPARKLE OPTICAL CORPORATION
Entity Type:Organization
Organization Name:EYE SPARKLE OPTICAL CORPORATION
Other - Org Name:EYE APPEAL OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-471-7710
Mailing Address - Street 1:1097 ROUTE 55
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5027
Mailing Address - Country:US
Mailing Address - Phone:845-471-7710
Mailing Address - Fax:
Practice Address - Street 1:1097 ROUTE 55 STE 4
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5027
Practice Address - Country:US
Practice Address - Phone:845-471-7710
Practice Address - Fax:845-471-7746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05210802Medicaid