=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275770208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAINTREE MALL EYECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2009
-----------------------------------------------------
Last Update Date | 01/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 GRANITE ST SUITE #1019
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-848-4481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 GRANITE ST SUITE #1019
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DENISE SNOW WILLIAMS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 781-848-8841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MA3651
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------