Provider Demographics
NPI:1174065460
Name:DE FARIA, LEONIS (OPTICIAN)
Entity type:Individual
Prefix:
First Name:LEONIS
Middle Name:
Last Name:DE FARIA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8311
Mailing Address - Country:US
Mailing Address - Phone:508-879-7642
Mailing Address - Fax:508-879-7672
Practice Address - Street 1:220 HOWARD ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8311
Practice Address - Country:US
Practice Address - Phone:508-879-7642
Practice Address - Fax:508-879-7672
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5688156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician