Provider Demographics
NPI:1700342987
Name:OPTICAL LAB
Entity Type:Organization
Organization Name:OPTICAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHALOM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZBERGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-954-4330
Mailing Address - Street 1:4620 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1104
Mailing Address - Country:US
Mailing Address - Phone:718-954-4330
Mailing Address - Fax:718-871-6322
Practice Address - Street 1:4620 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1104
Practice Address - Country:US
Practice Address - Phone:718-954-4330
Practice Address - Fax:718-871-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty