Provider Demographics
NPI:1982828091
Name:PLYMOUTH OPTICAL, INC.
Entity Type:Organization
Organization Name:PLYMOUTH OPTICAL, INC.
Other - Org Name:SPECS PERRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:ANDROS
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:413-567-3944
Mailing Address - Street 1:809 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2060
Mailing Address - Country:US
Mailing Address - Phone:413-567-3944
Mailing Address - Fax:
Practice Address - Street 1:809 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-2060
Practice Address - Country:US
Practice Address - Phone:413-567-3944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4195332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0159270001Medicare NSC