Provider Demographics
NPI:1558475053
Name:BAYSTATE EYE ASSOCIATES OF LEOMINSTER INC
Entity Type:Organization
Organization Name:BAYSTATE EYE ASSOCIATES OF LEOMINSTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-837-3790
Mailing Address - Street 1:25 SACK BLVD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3325
Mailing Address - Country:US
Mailing Address - Phone:508-837-3790
Mailing Address - Fax:978-534-3478
Practice Address - Street 1:25 SACK BLVD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3325
Practice Address - Country:US
Practice Address - Phone:978-537-2270
Practice Address - Fax:978-534-3478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9745564Medicaid
MA99828201OtherNETHEALTH
MA110067924/BMedicaid
MA9745564Medicaid
MA1003130001Medicare NSC