Healthcare Provider Details

I. General information

NPI: 1538719877
Provider Name (Legal Business Name): EXECUTIVE EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EXECUTIVE DR STE 201
MONMOUTH JUNCTION NJ
08852-2446
US

IV. Provider business mailing address

1 EXECUTIVE DR STE 201
MONMOUTH JUNCTION NJ
08852-2446
US

V. Phone/Fax

Practice location:
  • Phone: 732-297-7575
  • Fax: 732-297-9493
Mailing address:
  • Phone: 732-297-7575
  • Fax: 732-297-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: EDWARD NIEMCZYK
Title or Position: OWNER
Credential: OD
Phone: 732-297-7575