=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245668714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION CONSULTANTS OF NEW JERSEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2013
-----------------------------------------------------
Last Update Date | 10/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 W MAIN ST
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-780-0767
-----------------------------------------------------
Fax | 732-780-0787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3007 VANTAGE CT
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-493-3322
-----------------------------------------------------
Fax | 973-366-6486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. KELVIN T WIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 732-780-0767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00628400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------