Provider Demographics
NPI:1669686929
Name:PREMIER OPTICAL INC.
Entity Type:Organization
Organization Name:PREMIER OPTICAL INC.
Other - Org Name:FASHION OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:QUAMINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-266-1185
Mailing Address - Street 1:183 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3009
Mailing Address - Country:US
Mailing Address - Phone:617-266-1185
Mailing Address - Fax:617-262-6301
Practice Address - Street 1:183 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-3009
Practice Address - Country:US
Practice Address - Phone:617-266-1185
Practice Address - Fax:617-262-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5174332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9787534Medicaid
MA0040194OtherNEIGHBORHOOD HEALTH PLAN
MA9787534Medicaid