Healthcare Provider Details

I. General information

NPI: 1992255236
Provider Name (Legal Business Name): KOCH EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 VALLEY RD
MIDDLETOWN RI
02842-6400
US

IV. Provider business mailing address

175 PARAMOUNT DR SUITE 203
RAYNHAM MA
02767-1065
US

V. Phone/Fax

Practice location:
  • Phone: 401-849-4645
  • Fax:
Mailing address:
  • Phone: 774-320-3040
  • Fax: 508-910-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MARCELLO CELENTANO
Title or Position: CEO
Credential:
Phone: 774-320-3040