Provider Demographics
NPI:1902297955
Name:IMMACULATE VISION, LLC
Entity Type:Organization
Organization Name:IMMACULATE VISION, LLC
Other - Org Name:COHEN'S FASHION OPICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-880-9008
Mailing Address - Street 1:101 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1130
Mailing Address - Country:US
Mailing Address - Phone:617-542-9221
Mailing Address - Fax:617-542-9216
Practice Address - Street 1:328 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-5121
Practice Address - Country:US
Practice Address - Phone:617-542-9221
Practice Address - Fax:617-542-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4558332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier