=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689977787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLY EYECARE LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2010
-----------------------------------------------------
Last Update Date | 11/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 STATE RT 23
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07457-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-831-8381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 STATE ROUTE 23 NORTH
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-831-8381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. LISA V GAINES-SMITH
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 973-831-8381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00522700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------