Provider Demographics
NPI:1417672999
Name:PACIFIC OPTOMETRY SERVICE LLC
Entity Type:Organization
Organization Name:PACIFIC OPTOMETRY SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-613-0225
Mailing Address - Street 1:40 CALEB DYER LN
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03748-3553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 CALEB DYER LN
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:NH
Practice Address - Zip Code:03748-3553
Practice Address - Country:US
Practice Address - Phone:248-613-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty