Provider Demographics
NPI:1649299736
Name:HERITAGE OPTICAL
Entity type:Organization
Organization Name:HERITAGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:THEROUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-762-5599
Mailing Address - Street 1:255 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4705
Mailing Address - Country:US
Mailing Address - Phone:401-762-5599
Mailing Address - Fax:
Practice Address - Street 1:255 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-762-5599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI38061OtherDAVIS VISION
RI4017625599OtherVISION SERVICE PLAN
RI30231973OtherNEIGHBORHOOD HEALTH PLAN
RI9007936Medicaid
RI9007936Medicaid