Provider Demographics
NPI:1093733610
Name:VISIONARY EYE CARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:VISIONARY EYE CARE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:856-359-3654
Mailing Address - Street 1:100 CENTERTON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6103
Mailing Address - Country:US
Mailing Address - Phone:856-359-3654
Mailing Address - Fax:856-359-3680
Practice Address - Street 1:100 CENTERTON RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-6103
Practice Address - Country:US
Practice Address - Phone:856-359-3654
Practice Address - Fax:856-359-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2022-02-17
Deactivation Date:2022-01-28
Deactivation Code:
Reactivation Date:2022-02-17
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00554300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ104339OtherMEDICARE PTAN