Healthcare Provider Details

I. General information

NPI: 1083614838
Provider Name (Legal Business Name): JEANINE PREVOST OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 WILBUR AVE
SOMERSET MA
02725-1816
US

IV. Provider business mailing address

1287 WILBUR AVE
SOMERSET MA
02725-1816
US

V. Phone/Fax

Practice location:
  • Phone: 508-673-2140
  • Fax:
Mailing address:
  • Phone: 508-676-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3366
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: