Healthcare Provider Details

I. General information

NPI: 1407160120
Provider Name (Legal Business Name): MASCOMA EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HANOVER STREET SUITE 3A
LEBANON NH
03766-1334
US

IV. Provider business mailing address

24 HANOVER STREET SUITE 3A
LEBANON NH
03766-1334
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-2111
  • Fax: 603-448-2443
Mailing address:
  • Phone: 603-448-2111
  • Fax: 603-448-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0464
License Number StateNH

VIII. Authorized Official

Name: DR. EDWARD C WARREN JR.
Title or Position: OWNER
Credential: O.D.
Phone: 603-448-2111