Provider Demographics
NPI:1801083050
Name:COOPERCRWN NJ
Entity type:Organization
Organization Name:COOPERCRWN NJ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-731-3587
Mailing Address - Street 1:225 BROAD AVE
Mailing Address - Street 2:SUITE#206
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1588
Mailing Address - Country:US
Mailing Address - Phone:201-585-1337
Mailing Address - Fax:201-585-2998
Practice Address - Street 1:225 BROAD AVE
Practice Address - Street 2:SUITE#206
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1588
Practice Address - Country:US
Practice Address - Phone:201-585-1337
Practice Address - Fax:201-585-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00465400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5084601Medicaid
NJY19839Medicare UPIN
NJ084328Medicare Oscar/Certification
NJ5084601Medicaid