Provider Demographics
NPI:1770726226
Name:OPTICAL PALACE OF HARRISON LLC.
Entity type:Organization
Organization Name:OPTICAL PALACE OF HARRISON LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAITHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-724-3646
Mailing Address - Street 1:230 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-1329
Mailing Address - Country:US
Mailing Address - Phone:973-482-0777
Mailing Address - Fax:973-482-1330
Practice Address - Street 1:230 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-1329
Practice Address - Country:US
Practice Address - Phone:973-482-0777
Practice Address - Fax:973-482-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0071811Medicaid