Basic Information
Provider Information | |||||||||
NPI: | 1730772724 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONGWOOD EYE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 33 RIDDELL ST | ||||||||
Address2: |   | ||||||||
City: | GREENFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 013012025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137747016 | ||||||||
FaxNumber: | 4137737596 | ||||||||
Practice Location | |||||||||
Address1: | 180 DAGGETT DR | ||||||||
Address2: |   | ||||||||
City: | WEST SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 010894667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4134524111 | ||||||||
FaxNumber: | 4137737596 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2021 | ||||||||
LastUpdateDate: | 02/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STINNETT | ||||||||
AuthorizedOfficialFirstName: | GWENN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8285511157 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.