1447529557 NPI number — EYE CENTERS OF AMERICA, LLC

Table of content: (NPI 1447529557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447529557 NPI number — EYE CENTERS OF AMERICA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CENTERS OF AMERICA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447529557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1255 BROAD ST
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-707-7057
Provider Business Mailing Address Fax Number:
973-337-8361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 41ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07087-3793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-866-2440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ESTEVEZ
Authorized Official First Name:
JOSELYN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
201-866-2440

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  27OA00505700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0293016 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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