Provider Demographics
NPI:1255887964
Name:WAYNE OPTOMETRIC ASSOCIATES LLC
Entity type:Organization
Organization Name:WAYNE OPTOMETRIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIWIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-633-1234
Mailing Address - Street 1:1595-2 ROUTE 23 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7508
Mailing Address - Country:US
Mailing Address - Phone:973-633-1234
Mailing Address - Fax:973-633-1307
Practice Address - Street 1:1595-2 RT. 23 SO.
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7508
Practice Address - Country:US
Practice Address - Phone:973-633-1234
Practice Address - Fax:973-633-1307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OM00061200152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty