Provider Demographics
NPI:1063047827
Name:BEAUVILET, JEREMIAH (OPTICIAN)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:BEAUVILET
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 1:519 LAKE VISTA CIR APT I
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-5250
Mailing Address - Country:US
Mailing Address - Phone:845-414-4632
Mailing Address - Fax:
Practice Address - Street 1:519 LAKE VISTA CIR APT I
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-5250
Practice Address - Country:US
Practice Address - Phone:845-414-4632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician