1205871928 NPI number — PREMIUM EYE CARE, PC

Table of content: (NPI 1205871928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205871928 NPI number — PREMIUM EYE CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM EYE CARE, PC
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:
WESTWOOD EYECARE AND OPTICAL
Provider Other Organization Name Type Code:
3
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:
1205871928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
738 HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTWOOD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02090-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-329-5454
Provider Business Mailing Address Fax Number:
781-329-7813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
738 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTWOOD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02090-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-329-5454
Provider Business Practice Location Address Fax Number:
781-329-7813
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAVALLEE
Authorized Official First Name:
CORY
Authorized Official Middle Name:
Authorized Official Title or Position:
OD, OWNER
Authorized Official Telephone Number:
781-329-5454

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3168 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9761934 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 024505659 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 37955 . This is a "DAVIS VISION PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 22-00367 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 720677 . This is a "TUFTS HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 93921 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 410022567 . This is a "RAILROAD RETIREMENT FUND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 15214 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4014765-002 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W20038 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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