1477079697 NPI number — ADVANCED FAMILY EYECARE

Table of content: MARIE SUEZZETTE WALKER (NPI 1790317527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477079697 NPI number — ADVANCED FAMILY EYECARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FAMILY EYECARE
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:
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:
1477079697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3070 BRISTOL PIKE STE 2-220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENSALEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19020-5361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-497-1001
Provider Business Mailing Address Fax Number:
215-639-2486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 S MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROCK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07452-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-444-8277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
SIMKI
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
201-444-8277

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  27OA00592000 , 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: 1037105 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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