Provider Demographics
NPI:1912171471
Name:PLYMOUTH OPTICAL
Entity Type:Organization
Organization Name:PLYMOUTH OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KASS
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:603-536-3569
Mailing Address - Street 1:607 TENNEY MOUNTAIN HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3156
Mailing Address - Country:US
Mailing Address - Phone:603-536-3569
Mailing Address - Fax:603-536-3654
Practice Address - Street 1:607 TENNEY MOUNTAIN HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3156
Practice Address - Country:US
Practice Address - Phone:603-536-3569
Practice Address - Fax:603-536-3654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0780050001Medicare NSC