Healthcare Provider Details

I. General information

NPI: 1841657426
Provider Name (Legal Business Name): RENEE M GOMEZ-CHLEBICA OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109-6 MASONIC HOME RD.
CHARLTON MA
01507
US

IV. Provider business mailing address

109-6 MASONIC HOME RD.
CHARLTON MA
01507
US

V. Phone/Fax

Practice location:
  • Phone: 508-248-1188
  • Fax:
Mailing address:
  • Phone: 508-248-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4813
License Number StateMA

VIII. Authorized Official

Name: RENEE MIGNON GOMEZ CHLEBICA
Title or Position: OPTOMETRIST/OWNER
Credential: O.D.
Phone: 508-248-1188