Provider Demographics
NPI:1780720748
Name:MINEOLA OPTICAL BOUTIQUE INC
Entity type:Organization
Organization Name:MINEOLA OPTICAL BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BACOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:516-248-5554
Mailing Address - Street 1:330 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4187
Mailing Address - Country:US
Mailing Address - Phone:516-248-5554
Mailing Address - Fax:516-739-6620
Practice Address - Street 1:330 OLD COUNTRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4187
Practice Address - Country:US
Practice Address - Phone:516-248-5554
Practice Address - Fax:516-739-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3126332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0751840001Medicare NSC