1225197551 NPI number — PROGRESSIVE EYE CARE INC

Table of content: (NPI 1225197551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225197551 NPI number — PROGRESSIVE EYE CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE EYE CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225197551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1449 OLD WATERBURY RD
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-3926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-267-2020
Provider Business Mailing Address Fax Number:
203-267-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1449 OLD WATERBURY RD
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-267-2020
Provider Business Practice Location Address Fax Number:
203-267-2021
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBALL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-267-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004180684 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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