Provider Demographics
NPI:1326237306
Name:MALL VISION CENTER, LLC
Entity Type:Organization
Organization Name:MALL VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-778-9473
Mailing Address - Street 1:113 CORPORATION ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-2204
Mailing Address - Country:US
Mailing Address - Phone:508-778-9473
Mailing Address - Fax:508-775-5913
Practice Address - Street 1:113 CORPORATION ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2204
Practice Address - Country:US
Practice Address - Phone:508-778-9473
Practice Address - Fax:508-775-5913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4341610001Medicare NSC