Provider Demographics
NPI:1982700043
Name:RETTOC OPTICAL SERVICE
Entity type:Organization
Organization Name:RETTOC OPTICAL SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-289-7929
Mailing Address - Street 1:80 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5305
Mailing Address - Country:US
Mailing Address - Phone:781-289-7929
Mailing Address - Fax:
Practice Address - Street 1:80 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5305
Practice Address - Country:US
Practice Address - Phone:781-289-7929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3044332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCQ029OtherEMPIRE BCBS
MA000122654OtherBLUE CROSS/MEDEX/PARKWAY
MA1511327Medicaid
MA0000Q03964OtherBCBS/MEDEX/RETTOC
MA0451750001Medicare NSC