Provider Demographics
NPI:1881790673
Name:KLM OPTICAL, INC
Entity type:Organization
Organization Name:KLM OPTICAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-365-4066
Mailing Address - Street 1:1085D NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1632
Mailing Address - Country:US
Mailing Address - Phone:516-365-4066
Mailing Address - Fax:516-365-9312
Practice Address - Street 1:1085D NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1632
Practice Address - Country:US
Practice Address - Phone:516-365-4066
Practice Address - Fax:516-365-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005159-1156FX1800X
NY005191-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1002050000OtherUFT
NY18046OtherDAVIS VISION
NY02604960Medicaid
NYNY5159OtherEYEMED
NY837OtherVISION SCREENING
NY18046OtherDAVIS VISION
NY0841770001Medicare NSC