Healthcare Provider Details

I. General information

NPI: 1285789719
Provider Name (Legal Business Name): MANCHESTER BRICK VISION CENTER 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 ROUTE 70
MANCHESTER NJ
08759
US

IV. Provider business mailing address

1015 ROUTE 70
MANCHESTER NJ
08759
US

V. Phone/Fax

Practice location:
  • Phone: 732-657-1400
  • Fax:
Mailing address:
  • Phone: 732-657-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNJ5293
License Number StateNJ

VIII. Authorized Official

Name: DR. DONNA MALLOY
Title or Position: OWNER
Credential:
Phone: 732-657-1400