Provider Demographics
NPI:1881806917
Name:JACKSON HEIGHTS OPTICAL INC
Entity type:Organization
Organization Name:JACKSON HEIGHTS OPTICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-426-2725
Mailing Address - Street 1:58-27 198 STREET
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:718-224-0315
Mailing Address - Fax:718-426-9748
Practice Address - Street 1:83-25 37TH AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-426-2725
Practice Address - Fax:718-426-9748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005864-1152W00000X
NYTUV007098-1152W00000X
NYTUV006744-1152W00000X
NY006945-1156FX1800X
NYVUT005856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty