Provider Demographics
NPI:1548477821
Name:CEDARVILLE EYE ASSOCIATES PC
Entity type:Organization
Organization Name:CEDARVILLE EYE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:508-837-3790
Mailing Address - Street 1:2277 STATE RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-7111
Mailing Address - Country:US
Mailing Address - Phone:508-837-3790
Mailing Address - Fax:508-833-3551
Practice Address - Street 1:2277 STATE RD
Practice Address - Street 2:SUITE F
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7111
Practice Address - Country:US
Practice Address - Phone:508-888-6393
Practice Address - Fax:508-833-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA151342OtherHARVARD PILGRIM
MAW20418OtherBLUE CROSS
MA0391824Medicaid
MAW15969Medicare UPIN
MA5942380001Medicare NSC
W1596901Medicare PIN