Provider Demographics
NPI:1467903880
Name:ANGEL EYECARE LLC
Entity Type:Organization
Organization Name:ANGEL EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:973-392-3182
Mailing Address - Street 1:69 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1705
Mailing Address - Country:US
Mailing Address - Phone:973-392-3182
Mailing Address - Fax:
Practice Address - Street 1:1 TETERBORO LANDING DR
Practice Address - Street 2:INSIDE WALMART VISION CENTER
Practice Address - City:TETERBORO
Practice Address - State:NJ
Practice Address - Zip Code:07608
Practice Address - Country:US
Practice Address - Phone:201-375-4005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00595000152W00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0519081Medicaid