Provider Demographics
NPI:1356528061
Name:EDWARDS OPTICAL LAB INC.
Entity type:Organization
Organization Name:EDWARDS OPTICAL LAB INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-771-2834
Mailing Address - Street 1:768 IYANOUGH RD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601
Mailing Address - Country:US
Mailing Address - Phone:508-771-2834
Mailing Address - Fax:508-771-5833
Practice Address - Street 1:768 IYANOUGH RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-771-2834
Practice Address - Fax:508-771-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4038332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0894970001Medicare UPIN