Healthcare Provider Details

I. General information

NPI: 1841628435
Provider Name (Legal Business Name): OMG OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 WASHINGTON ST
BRIGHTON MA
02135-3322
US

IV. Provider business mailing address

357 WASHINGTON ST
BRIGHTON MA
02135-3322
US

V. Phone/Fax

Practice location:
  • Phone: 617-903-3815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number5184
License Number StateMA

VIII. Authorized Official

Name: MARGARET GOODALE
Title or Position: OPTICIAN/OWNER
Credential: R.D.O.
Phone: 617-903-3815