Provider Demographics
NPI:1912059882
Name:BANVILLE OPTICAL INC.
Entity Type:Organization
Organization Name:BANVILLE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIZKALLA
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:978-745-2774
Mailing Address - Street 1:88 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3625
Mailing Address - Country:US
Mailing Address - Phone:978-745-2774
Mailing Address - Fax:978-745-9317
Practice Address - Street 1:88 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3625
Practice Address - Country:US
Practice Address - Phone:978-745-2774
Practice Address - Fax:978-745-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4281156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0132670001Medicare ID - Type UnspecifiedPROVIDER NUMBER