1003900382 NPI number — FAMILY EYE CARE CENTER & OPTICAL GALLERY INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003900382 NPI number — FAMILY EYE CARE CENTER & OPTICAL GALLERY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY EYE CARE CENTER & OPTICAL GALLERY INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003900382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 CORNERSTONE SQUARE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WESTFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01886-3198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-692-1400
Provider Business Mailing Address Fax Number:
978-692-5995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 CORNERSTONE SQUARE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WESTFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01886-3198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-692-1400
Provider Business Practice Location Address Fax Number:
978-692-5995
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAHAROZIAN
Authorized Official First Name:
DWAYNE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-692-1400

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 740025 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9775137 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M16086 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 150559 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 23648 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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