Healthcare Provider Details

I. General information

NPI: 1053496497
Provider Name (Legal Business Name): BOSTON LASER EYE INSTITUTE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/08/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WEBSTER PL
BROOKLINE MA
02445-7937
US

IV. Provider business mailing address

24 WEBSTER PL
BROOKLINE MA
02445-7937
US

V. Phone/Fax

Practice location:
  • Phone: 617-202-2020
  • Fax: 617-734-3264
Mailing address:
  • Phone: 617-202-2020
  • Fax: 617-734-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA6694
License Number StateMA

VIII. Authorized Official

Name: EILEEN PECK
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 617-202-2020