Provider Demographics
NPI:1356660393
Name:PORTER SQUARE EYE ASSOCIATES INC
Entity Type:Organization
Organization Name:PORTER SQUARE EYE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLAAHSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:617-864-3147
Mailing Address - Street 1:2038 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2104
Mailing Address - Country:US
Mailing Address - Phone:617-864-3147
Mailing Address - Fax:
Practice Address - Street 1:2038 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2104
Practice Address - Country:US
Practice Address - Phone:617-864-3147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty