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General NPI Number Information
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NPI Number | 1083894943
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Entity Type | Organization
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Legal Business Name | ELITE EYECARE ASSOCIATES, PC
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Dates
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Enumeration Date | 11/08/2007
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Last Update Date | 02/10/2012
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Provider Practice Location Address
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Address Line | 707 LIBERTY PL LAKESIDE BUSINESS PARK
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-5715
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Country | US
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Telephone | 185-687-5002
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Fax | 185-651-3642
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Provider Business Mailing Address
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Address Line | 707 LIBERTY PL LAKESIDE BUSINESS PARK
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-5715
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Country | US
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Telephone | 185-687-5002
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Fax | 185-651-3642
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Authorized Official
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Title or Position | OPTOMETRIC PHYSICIAN
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Name | DR. JOHN SCOT ELLIS SR.
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Credential | OD
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Telephone | 18568750022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 27OA00505600
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License Number State | NJ
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