Healthcare Provider Details

I. General information

NPI: 1821007261
Provider Name (Legal Business Name): BANNETT EYE CENTERS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N BROAD ST
WOODBURY NJ
08096-1795
US

IV. Provider business mailing address

620 N BROAD ST
WOODBURY NJ
08096-1795
US

V. Phone/Fax

Practice location:
  • Phone: 856-853-5554
  • Fax: 856-853-5650
Mailing address:
  • Phone: 856-853-5554
  • Fax: 856-853-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB04846500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JULIE BLINDERMAN BANNETT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 856-853-5554