Basic Information
| Provider Information | |||||||||
| NPI: | 1780600536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANEDY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 5612 | MA | Y | Eye and Vision Services Providers | Technician/Technologist | Optician | 156FX1800X | 568 | NH | N | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 0317454 | 05 | MA | MEDICAID | 30750750 | 05 | NH | MEDICAID |