Provider Demographics
NPI:1174732127
Name:CONCORD OPTICAL
Entity type:Organization
Organization Name:CONCORD OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EYEGLASS CZAR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:II
Authorized Official - Credentials:LDO
Authorized Official - Phone:978-369-6707
Mailing Address - Street 1:80 THOREAU ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2409
Mailing Address - Country:US
Mailing Address - Phone:978-369-6707
Mailing Address - Fax:978-369-1880
Practice Address - Street 1:80 THOREAU ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2409
Practice Address - Country:US
Practice Address - Phone:978-369-6707
Practice Address - Fax:978-369-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5767156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty