Provider Demographics
NPI:1356512511
Name:TKO OPTICAL INC.
Entity type:Organization
Organization Name:TKO OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-674-3808
Mailing Address - Street 1:582 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:582 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1936
Practice Address - Country:US
Practice Address - Phone:973-674-3808
Practice Address - Fax:973-674-3943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD180700332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6012809Medicaid