Provider Demographics
NPI:1295953768
Name:WICKFORD OPTICAL, LLC
Entity type:Organization
Organization Name:WICKFORD OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:COPPOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:401-294-1010
Mailing Address - Street 1:7805 POST RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4405
Mailing Address - Country:US
Mailing Address - Phone:401-294-1010
Mailing Address - Fax:401-295-2050
Practice Address - Street 1:7805 POST RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4405
Practice Address - Country:US
Practice Address - Phone:401-294-1010
Practice Address - Fax:401-295-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG 00369332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIWO16877Medicaid
RIWO16877Medicaid