Provider Demographics
NPI:1245356062
Name:EDISON OPTICAL CORPORATION
Entity type:Organization
Organization Name:EDISON OPTICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCENENY
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:732-738-1904
Mailing Address - Street 1:940 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2811
Mailing Address - Country:US
Mailing Address - Phone:738-738-1904
Mailing Address - Fax:732-738-6006
Practice Address - Street 1:940 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2811
Practice Address - Country:US
Practice Address - Phone:738-738-1904
Practice Address - Fax:732-738-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0506070001Medicare NSC
NJ207474Medicare PIN