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General NPI Number Information
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NPI Number | 1407397011
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Entity Type | Organization
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Legal Business Name | PROVISION FAMILY EYE CARE
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Dates
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Enumeration Date | 03/15/2017
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Last Update Date | 03/15/2017
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Provider Practice Location Address
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Address Line | 3452 BROIDY RD MCGUIRE AFB
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City | TRENTON
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State | NJ
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Zip | 08641-5305
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Country | US
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Telephone | 609-723-8957
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Fax |
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Provider Business Mailing Address
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Address Line | 3452 BROIDY RD MCGUIRE AFB
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City | TRENTON
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State | NJ
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Zip | 08641-5305
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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 | MONIKA WYSOCZANSKA
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Credential | OD
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Telephone | 609-723-8957
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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 | 27OA00611200
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License Number State | NJ
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