1528274719 NPI number — LASER AND VISION SURGERY CENTER, LLC

Table of content: (NPI 1528274719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528274719 NPI number — LASER AND VISION SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LASER AND VISION SURGERY CENTER, LLC
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:
1528274719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
178 HARTFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06040-5986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-649-9973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
178 HARTFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06040-5986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-649-9973
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CASTALDI
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
860-643-3900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  0163 , 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: 17402 . This is a "SPECTRA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 352 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 117819 . This is a "EYEMED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004207032 . This is a "MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 774128 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A2021364 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2380780 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 490004322 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: IV7858 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 20472 . This is a "COLE MANAGED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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