Provider Demographics
NPI:1184819518
Name:LEA OPTOMETRIC. PC
Entity Type:Organization
Organization Name:LEA OPTOMETRIC. PC
Other - Org Name:THE NEWBURYPORT OPTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCLOUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:978-465-2405
Mailing Address - Street 1:28 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-6605
Mailing Address - Country:US
Mailing Address - Phone:978-465-2405
Mailing Address - Fax:978-463-4377
Practice Address - Street 1:28 STATE ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-6605
Practice Address - Country:US
Practice Address - Phone:978-465-2405
Practice Address - Fax:978-463-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4245152W00000X
MA4411152W00000X
MA3780152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAV03166Medicare UPIN
MAU87332Medicare UPIN