Provider Demographics
NPI:1346228285
Name:CLINTON FAMILY EYECARE CENTER, LLC
Entity Type:Organization
Organization Name:CLINTON FAMILY EYECARE CENTER, LLC
Other - Org Name:CLINTON FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:BLYSKAL
Authorized Official - Last Name:MARCOLINI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:908-735-5712
Mailing Address - Street 1:186 CENTER ST
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1385
Mailing Address - Country:US
Mailing Address - Phone:908-735-5712
Mailing Address - Fax:908-735-5715
Practice Address - Street 1:186 CENTER ST
Practice Address - Street 2:SUITE 170
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1385
Practice Address - Country:US
Practice Address - Phone:908-735-5712
Practice Address - Fax:908-735-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-31
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA00573300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8666202Medicaid
NJ8666202Medicaid
NJ106713Medicare PIN