Healthcare Provider Details

I. General information

NPI: 1497303127
Provider Name (Legal Business Name): NORTHEAST PEDIATRIC EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 TICKLEFANCY LN
SALEM NH
03079-4044
US

IV. Provider business mailing address

22 TICKLEFANCY LN
SALEM NH
03079-4044
US

V. Phone/Fax

Practice location:
  • Phone: 401-829-9173
  • Fax:
Mailing address:
  • Phone: 401-829-9173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA WONG
Title or Position: PRESIDENT
Credential: MD
Phone: 401-829-9173