Provider Demographics
NPI:1801072681
Name:PUBLIC SPECTACLE OPTICIANS
Entity type:Organization
Organization Name:PUBLIC SPECTACLE OPTICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:DORITY
Authorized Official - Last Name:MACLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:508-746-8880
Mailing Address - Street 1:53 COURT STREET
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3822
Mailing Address - Country:US
Mailing Address - Phone:508-746-8880
Mailing Address - Fax:508-746-5752
Practice Address - Street 1:53 COURT STREET
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3822
Practice Address - Country:US
Practice Address - Phone:508-746-8880
Practice Address - Fax:508-746-5752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2044156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1523341Medicaid
MA0280120001Medicare NSC