Provider Demographics
NPI:1871991570
Name:THE OPTIC NERVE, INC.
Entity type:Organization
Organization Name:THE OPTIC NERVE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-985-1300
Mailing Address - Street 1:163 ROUTE 73 S
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4120
Mailing Address - Country:US
Mailing Address - Phone:856-985-1300
Mailing Address - Fax:856-985-1346
Practice Address - Street 1:163 ROUTE 73 S
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4120
Practice Address - Country:US
Practice Address - Phone:856-985-1300
Practice Address - Fax:856-985-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00342201156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty