MEDICARE: RAVINE EYE CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	27OA00453001	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1700839743	OTHER	NJ	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1700839743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVINE EYE CENTER INC

Provider Business Mailing Address
First Line	:	1722 NEW BEDFORD RD
Second Line	:
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-3867
Country	:	US
Telephone Number	:	732-974-1400
Fax Number	:	732-974-2121

Provider Business Practice Location Address
First Line	:	1722 NEW BEDFORD RD
Second Line	:
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-3867
Country	:	US
Telephone Number	:	732-974-1400
Fax Number	:	732-974-2121

Authorized Official
Title or Position	:	VICE PRES
Name	:	DR. SHELLI L RAVINE
Credential	:	OD
Telephone Number	:	732-974-1400

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	05/06/2008

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Directions to “RAVINE EYE CENTER INC ” Practice Location

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