Healthcare Provider Details

I. General information

NPI: 1720410558
Provider Name (Legal Business Name): PERFECT VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2013
Last Update Date: 08/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 COMMONWEALTH AVE
BOSTON MA
02215-2447
US

IV. Provider business mailing address

710 COMMONWEALTH AVE
BOSTON MA
02215-2447
US

V. Phone/Fax

Practice location:
  • Phone: 617-262-3145
  • Fax:
Mailing address:
  • Phone: 617-262-3145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMA4558
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberMA4558
License Number StateMA

VIII. Authorized Official

Name: DR. DARRYL GRACE
Title or Position: OWNER
Credential: OD
Phone: 617-262-3145