=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306205224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NJ EYE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2016
-----------------------------------------------------
Last Update Date | 02/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 DELSEA DR N
-----------------------------------------------------
City | GLASSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08028-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-582-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 DELSEA DR N
-----------------------------------------------------
City | GLASSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08028-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-582-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PEARLE VISION OPERATOR
-----------------------------------------------------
Name | MR. PAUL M RUDOLPH
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 856-582-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | TD 2070
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------