1104465939 NPI number — WILD APPLE EYE LLC

Table of content: (NPI 1104465939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104465939 NPI number — WILD APPLE EYE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILD APPLE EYE 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:
1104465939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 BOKUM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD SAYBROOK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06475-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-391-3366
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 MAIN ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERBROOK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06409-1057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-767-3206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PARADIS
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
860-577-2012

Provider Taxonomy Codes

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

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

  • Identifier: 8073265 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: A31568 . This is a "EYEMED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 139866 . This is a "CTCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4002760 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P5740240 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 12002152 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1473930 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".




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