Healthcare Provider Details

I. General information

NPI: 1467903880
Provider Name (Legal Business Name): ANGEL EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TETERBORO LANDING DR INSIDE WALMART VISION CENTER
TETERBORO NJ
07608
US

IV. Provider business mailing address

69 CENTER ST
BELLEVILLE NJ
07109-1705
US

V. Phone/Fax

Practice location:
  • Phone: 201-375-4005
  • Fax:
Mailing address:
  • Phone: 973-392-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00595000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHIRLEY G ANGEL
Title or Position: OWNER
Credential: O.D.
Phone: 973-392-3182