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General NPI Number Information
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NPI Number | 1003144833
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Entity Type | Organization
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Legal Business Name | FORT LEE VISION LLC
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Dates
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Enumeration Date | 12/07/2009
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Last Update Date | 12/11/2014
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Provider Practice Location Address
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Address Line | 2151 LEMOINE AVE
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City | FORT LEE
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State | NJ
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Zip | 07024-6041
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Country | US
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Telephone | 201-346-9000
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Fax | 201-346-9001
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Provider Business Mailing Address
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Address Line | 2151 LEMOINE AVE
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City | FORT LEE
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State | NJ
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Zip | 07024-6041
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Country | US
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Telephone | 201-346-9000
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Fax | 201-346-9001
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Authorized Official
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Title or Position | O.D./OWNER
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Name | DR. DIANE M. KIM
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Credential | O.D.
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Telephone | 201-346-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 27OA00602800
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License Number State | NJ
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