Provider Demographics
NPI:1396281564
Name:FANWOOD EYE CARE LLC
Entity type:Organization
Organization Name:FANWOOD EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:908-288-7227
Mailing Address - Street 1:246 SOUTH AVE
Mailing Address - Street 2:#106
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 SOUTH AVE
Practice Address - Street 2:#106
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1220
Practice Address - Country:US
Practice Address - Phone:978-987-0698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00643700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty