Basic Information
| Provider Information | |||||||||
| NPI: | 1417543034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PLANEYE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE EYE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 MARKET DR | ||||||||
| Address2: | |||||||||
| City: | ATHOL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013319829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789393128 | ||||||||
| FaxNumber: | 9786502090 | ||||||||
| Practice Location | |||||||||
| Address1: | 184 MARKET DR | ||||||||
| Address2: | |||||||||
| City: | ATHOL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013319829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789393128 | ||||||||
| FaxNumber: | 9786502090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNIFF | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9789393128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | A23165 | 05 | MA | MEDICAID |