Provider Demographics
NPI:1124710744
Name:SOULLIARD, CHELSEA L
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:L
Last Name:SOULLIARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COOPERTOWNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-1433
Mailing Address - Country:US
Mailing Address - Phone:856-545-9057
Mailing Address - Fax:856-629-1297
Practice Address - Street 1:1 COOPERTOWNE BLVD
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1433
Practice Address - Country:US
Practice Address - Phone:856-545-9057
Practice Address - Fax:856-629-1297
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00397100156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician