Provider Demographics
NPI:1043498439
Name:PRO-VAC, INC
Entity type:Organization
Organization Name:PRO-VAC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDANT/OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLETTA
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:732-892-7717
Mailing Address - Street 1:2315 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-4329
Mailing Address - Country:US
Mailing Address - Phone:732-892-7717
Mailing Address - Fax:732-892-7836
Practice Address - Street 1:2315 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-4329
Practice Address - Country:US
Practice Address - Phone:732-892-7717
Practice Address - Fax:732-892-7836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00300700332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ313227OtherNVA
NJ110308OtherEYE MED
NJ1K8390OtherHEALTH NET
NJ8577803Medicaid
NJ02719OtherSPECTERA
NJ1K8390OtherHEALTH NET
NJ4257320001Medicare NSC