Basic Information
| Provider Information | |||||||||
| NPI: | 1780661660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLICK | ||||||||
| FirstName: | MARYELLEN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 ECHELON MALL | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080431943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567726331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 ECHELON MALL | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080431943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567726331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 27OA00460300 | NJ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.