Basic Information
| Provider Information | |||||||||
| NPI: | 1538719877 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXECUTIVE EYE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EXECUTIVE DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MONMOUTH JUNCTION | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088522446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322977575 | ||||||||
| FaxNumber: | 7322979493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EXECUTIVE DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MONMOUTH JUNCTION | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088522446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322977575 | ||||||||
| FaxNumber: | 7322979493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2019 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | NIEMCZYK | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7322977575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.