Healthcare Provider Details

I. General information

NPI: 1437597424
Provider Name (Legal Business Name): BAY STATE EXCELLENT VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MAIN ST
MALDEN MA
02148-3919
US

IV. Provider business mailing address

155 GRIFFIN RD # 1
PORTSMOUTH NH
03801-4125
US

V. Phone/Fax

Practice location:
  • Phone: 781-321-6463
  • Fax:
Mailing address:
  • Phone: 603-430-5225
  • Fax: 603-430-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN D MOSER
Title or Position: OFFICEMANAGER
Credential:
Phone: 603-430-5225