MEDICARE: CAMBRIDGE EYE GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	4687	MA
2	152WP0200X	Pediatric Optometrist	4689	MA
3	152WS0006X	Sports Vision Optometrist	4689	MA
4	152WV0400X	Vision Therapy Optometrist	4689	MA
5	152W00000X	Optometrist	4689	MA

General Provider Information

NPI Number	:	1235688557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMBRIDGE EYE GROUP INC

Provider Business Mailing Address
First Line	:	169 MONSIGNOR OBRIEN HWY
Second Line	:	415
City	:	CAMBRIDGE
State	:	MA
Zip	:	02141-1289
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 CONCORD AVE
Second Line	:	SUITE B
City	:	CAMBRIDGE
State	:	MA
Zip	:	02138-1197
Country	:	US
Telephone Number	:	617-818-0476
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACKY KONG
Credential	:
Telephone Number	:	617-818-0476

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/27/2016

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