Healthcare Provider Details

I. General information

NPI: 1295953768
Provider Name (Legal Business Name): WICKFORD OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7805 POST RD
NORTH KINGSTOWN RI
02852-4405
US

IV. Provider business mailing address

7805 POST RD
NORTH KINGSTOWN RI
02852-4405
US

V. Phone/Fax

Practice location:
  • Phone: 401-294-1010
  • Fax: 401-295-2050
Mailing address:
  • Phone: 401-294-1010
  • Fax: 401-295-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberODTG 00369
License Number StateRI

VIII. Authorized Official

Name: DR. DOMENIC A COPPOLINO
Title or Position: PARTNER
Credential: O.D.
Phone: 401-294-1010