=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992002794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYE HEALTH & VISION CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 02/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 PASSAIC ST
-----------------------------------------------------
City | GARFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07026-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-330-3554
-----------------------------------------------------
Fax | 973-773-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 PASSAIC ST
-----------------------------------------------------
City | GARFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07026-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-330-3554
-----------------------------------------------------
Fax | 973-773-0816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ATTEFA SULTANI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 917-495-6832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00624400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------