Healthcare Provider Details

I. General information

NPI: 1528837309
Provider Name (Legal Business Name): MSO DOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 MASSACHUSETTS AVE
CAMBRIDGE MA
02138-5247
US

IV. Provider business mailing address

1150 FRIENDLY WAY S
ST PETERSBURG FL
33705-6119
US

V. Phone/Fax

Practice location:
  • Phone: 617-547-3310
  • Fax: 617-547-3313
Mailing address:
  • Phone: 508-612-5273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ENRICO PALMERINO
Title or Position: VISIONARY
Credential:
Phone: 508-612-5273