=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295953768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WICKFORD OPTICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7805 POST RD
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-294-1010
-----------------------------------------------------
Fax | 401-295-2050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7805 POST RD
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-294-1010
-----------------------------------------------------
Fax | 401-295-2050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. DOMENIC A COPPOLINO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 401-294-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | ODTG 00369
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------