Provider Demographics
NPI:1750834107
Name:MILLTOWN VISION CARE
Entity Type:Organization
Organization Name:MILLTOWN VISION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:732-828-2246
Mailing Address - Street 1:36 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1571
Mailing Address - Country:US
Mailing Address - Phone:732-828-2246
Mailing Address - Fax:732-374-3004
Practice Address - Street 1:36 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1571
Practice Address - Country:US
Practice Address - Phone:732-828-2246
Practice Address - Fax:732-374-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA0043400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5848780001Medicare NSC