Provider Demographics
NPI:1407397011
Name:PROVISION FAMILY EYE CARE
Entity Type:Organization
Organization Name:PROVISION FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYSOCZANSKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:609-723-8957
Mailing Address - Street 1:3452 BROIDY RD
Mailing Address - Street 2:MCGUIRE AFB
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3452 BROIDY RD
Practice Address - Street 2:MCGUIRE AFB
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08641-5305
Practice Address - Country:US
Practice Address - Phone:609-723-8957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00611200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1376737924Medicare UPIN