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General NPI Number Information
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NPI Number | 1407160120
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Entity Type | Organization
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Legal Business Name | MASCOMA EYECARE
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Dates
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Enumeration Date | 08/05/2010
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Last Update Date | 08/05/2010
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Provider Practice Location Address
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Address Line | 24 HANOVER STREET SUITE 3A
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City | LEBANON
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State | NH
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Zip | 03766-1334
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Country | US
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Telephone | 603-448-2111
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Fax | 603-448-2443
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Provider Business Mailing Address
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Address Line | 24 HANOVER STREET SUITE 3A
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City | LEBANON
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State | NH
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Zip | 03766-1334
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Country | US
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Telephone | 603-448-2111
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Fax | 603-448-2443
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDWARD C WARREN JR.
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Credential | O.D.
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Telephone | 603-448-2111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0464
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License Number State | NH
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