Provider Demographics
NPI:1144468059
Name:PROVIDENCE OPTICIANS, INC.
Entity type:Organization
Organization Name:PROVIDENCE OPTICIANS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-462-0055
Mailing Address - Street 1:1802 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-5021
Mailing Address - Country:US
Mailing Address - Phone:202-462-0055
Mailing Address - Fax:202-462-2837
Practice Address - Street 1:1802 11TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-5021
Practice Address - Country:US
Practice Address - Phone:202-462-0055
Practice Address - Fax:202-462-2837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1538298906OtherBLOCK VISION
DC016707300Medicaid
DC016707300Medicaid