Provider Demographics
NPI:1942392576
Name:FAMILY EYE CARE CENTER & OPTICAL GALLERY, INC.
Entity Type:Organization
Organization Name:FAMILY EYE CARE CENTER & OPTICAL GALLERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THE FAMILY EYE CARE CENTER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAHAROZIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-692-1400
Mailing Address - Street 1:5 CORNERSTONE SQUARE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886
Mailing Address - Country:US
Mailing Address - Phone:978-692-1400
Mailing Address - Fax:978-692-5995
Practice Address - Street 1:5 CORNERSTONE SQUARE
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886
Practice Address - Country:US
Practice Address - Phone:978-692-1400
Practice Address - Fax:978-692-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1385156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1181330001Medicare NSC