Provider Demographics
NPI:1609177948
Name:EYE CENTER OF THE NORTH SHORE, LLC
Entity Type:Organization
Organization Name:EYE CENTER OF THE NORTH SHORE, LLC
Other - Org Name:EYE CENTER OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-744-1177
Mailing Address - Street 1:400 HIGHLAND AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-7003
Mailing Address - Country:US
Mailing Address - Phone:978-744-1177
Mailing Address - Fax:978-910-0507
Practice Address - Street 1:400 HIGHLAND AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7003
Practice Address - Country:US
Practice Address - Phone:978-744-1177
Practice Address - Fax:978-910-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087149AMedicaid
MA0015503OtherMEDICARE PTAN