MEDICARE: ELLIS' FAMILY EYECARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OA05056	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	124542	OTHER	NJ	PTAN

General Provider Information

NPI Number	:	1053598904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLIS' FAMILY EYECARE, LLC

Provider Business Mailing Address
First Line	:	691 ROUTE 9 S
Second Line	:	MILLERS MALL, UNIT 4
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-4020
Country	:	US
Telephone Number	:	609-294-8144
Fax Number	:	609-512-5190

Provider Business Practice Location Address
First Line	:	691 ROUTE 9 S
Second Line	:	MILLERS MALL, UNIT 4
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-4020
Country	:	US
Telephone Number	:	609-294-8144
Fax Number	:	609-512-5190

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN S ELLIS
Credential	:	OD
Telephone Number	:	609-294-8144

Provider Enumeration Date	:	01/23/2008
Last Update Date	:	02/10/2012

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