Provider Demographics
NPI:1083341259
Name:BROKE GLASSES GAL LLC
Entity Type:Organization
Organization Name:BROKE GLASSES GAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LETELLIER
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:603-915-6478
Mailing Address - Street 1:68 WHITELAW DR
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-4421
Mailing Address - Country:US
Mailing Address - Phone:603-915-6478
Mailing Address - Fax:
Practice Address - Street 1:486 WHITE MOUNTAIN HWY STE D
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-4215
Practice Address - Country:US
Practice Address - Phone:603-915-6478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-06
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty