Healthcare Provider Details

I. General information

NPI: 1477079697
Provider Name (Legal Business Name): ADVANCED FAMILY EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 S MAPLE AVE
GLEN ROCK NJ
07452-2820
US

IV. Provider business mailing address

3070 BRISTOL PIKE STE 2-220
BENSALEM PA
19020-5361
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-8277
  • Fax:
Mailing address:
  • Phone: 215-497-1001
  • Fax: 215-639-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number27OA00592000
License Number StateNJ

VIII. Authorized Official

Name: SIMKI SHAH
Title or Position: SOLE OWNER
Credential: OD
Phone: 201-444-8277