Provider Demographics
NPI:1700839743
Name:RAVINE EYE CENTER INC
Entity Type:Organization
Organization Name:RAVINE EYE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAVINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:732-974-1400
Mailing Address - Street 1:1722 NEW BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3867
Mailing Address - Country:US
Mailing Address - Phone:732-974-1400
Mailing Address - Fax:732-974-2121
Practice Address - Street 1:1722 NEW BEDFORD RD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3867
Practice Address - Country:US
Practice Address - Phone:732-974-1400
Practice Address - Fax:732-974-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00453001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1700839743OtherRAILROAD MEDICARE
NJ1700839743OtherRAILROAD MEDICARE
NJ102497Medicare PIN