Provider Demographics
NPI:1083731731
Name:WAYNE EYECARE OUTLET CENTER
Entity Type:Organization
Organization Name:WAYNE EYECARE OUTLET CENTER
Other - Org Name:CLEAR EYES RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIWIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-633-1617
Mailing Address - Street 1:1595-2 RT. 23 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470
Mailing Address - Country:US
Mailing Address - Phone:973-633-1617
Mailing Address - Fax:973-633-1307
Practice Address - Street 1:1595-2 RT. 23 SOUTH
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470
Practice Address - Country:US
Practice Address - Phone:973-633-1617
Practice Address - Fax:973-633-1307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD1183332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0850770001Medicare NSC