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General NPI Number Information
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NPI Number | 1376708313
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Entity Type | Organization
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Legal Business Name | SPARE PAIR IV
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Dates
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Enumeration Date | 07/18/2008
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Last Update Date | 07/18/2008
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Provider Practice Location Address
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Address Line | 2145 ROUTE 35
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City | HOLMDEL
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State | NJ
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Zip | 07733-1164
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Country | US
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Telephone | 732-335-0004
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Fax | 732-335-0006
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Provider Business Mailing Address
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Address Line | 2145 ROUTE 35
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City | HOLMDEL
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State | NJ
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Zip | 07733-1164
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Country | US
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Telephone | 732-335-0004
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Fax | 732-335-0006
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Authorized Official
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Title or Position | VP
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Name | JOHN A COLLINI
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Credential | OD
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Telephone | 732-335-0004
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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 | 5021
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License Number State | NJ
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