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General NPI Number Information
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NPI Number | 1396281564
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Entity Type | Organization
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Legal Business Name | FANWOOD EYE CARE LLC
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Dates
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Enumeration Date | 01/12/2017
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Last Update Date | 11/07/2017
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Provider Practice Location Address
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Address Line | 246 SOUTH AVE #106
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City | FANWOOD
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State | NJ
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Zip | 07023-1220
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Country | US
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Telephone | 978-987-0698
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Fax |
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Provider Business Mailing Address
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Address Line | 246 SOUTH AVE #106
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City | FANWOOD
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State | NJ
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Zip | 07023-1220
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KATHY SHIN
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Credential | OD
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Telephone | 908-288-7227
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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 | 27OA00643700
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License Number State | NJ
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