Provider Demographics
NPI:1457724668
Name:GALLERY EYECARE, LLC
Entity Type:Organization
Organization Name:GALLERY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS-MAHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:617-202-9650
Mailing Address - Street 1:2304 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3221
Mailing Address - Country:US
Mailing Address - Phone:617-202-9650
Mailing Address - Fax:617-202-9651
Practice Address - Street 1:2304 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3221
Practice Address - Country:US
Practice Address - Phone:617-202-9650
Practice Address - Fax:617-202-9651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083858AMedicaid
MA110083858AMedicaid