Provider Demographics
NPI:1962688051
Name:CHARLTON OPTICAL
Entity type:Organization
Organization Name:CHARLTON OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:MALY
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:508-248-1188
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:109-6 MASONIC HOME ROAD
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-0194
Mailing Address - Country:US
Mailing Address - Phone:508-248-1188
Mailing Address - Fax:508-248-5128
Practice Address - Street 1:109-6 MASONIC HOME ROAD
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507
Practice Address - Country:US
Practice Address - Phone:508-248-1188
Practice Address - Fax:508-248-5128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4511332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0842440001Medicare NSC