Provider Demographics
NPI:1215394945
Name:LAICO BOULOS, ASHLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:
Last Name:LAICO BOULOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2146
Mailing Address - Country:US
Mailing Address - Phone:800-530-2730
Mailing Address - Fax:
Practice Address - Street 1:1430 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2146
Practice Address - Country:US
Practice Address - Phone:800-530-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00661700152W00000X
PAOEG003087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist