Healthcare Provider Details

I. General information

NPI: 1740432889
Provider Name (Legal Business Name): LEONARD C. SHWOM RDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

584 HIGH ST
DEDHAM MA
02026-1807
US

IV. Provider business mailing address

584 HIGH ST
DEDHAM MA
02026-1807
US

V. Phone/Fax

Practice location:
  • Phone: 781-471-4337
  • Fax: 781-471-4339
Mailing address:
  • Phone: 781-471-4337
  • Fax: 781-471-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1372
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: