Provider Demographics
NPI:1497817712
Name:PROFESSIONAL OPTICIAN MANAGEMENT SERVICES INC
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICIAN MANAGEMENT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LO LICENSED OPTICIAN
Authorized Official - Phone:860-442-6868
Mailing Address - Street 1:741 BROAD STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385
Mailing Address - Country:US
Mailing Address - Phone:860-442-6868
Mailing Address - Fax:860-437-8222
Practice Address - Street 1:741 BROAD STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-442-6868
Practice Address - Fax:860-437-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTL0679156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0700130001Medicare ID - Type Unspecified