1457780538 NPI number — THE EYE CARE GROUP, PC

Table of content: (NPI 1457780538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457780538 NPI number — THE EYE CARE GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EYE CARE GROUP, PC
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:
1457780538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-3105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-573-4885
Provider Business Mailing Address Fax Number:
203-401-6517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 BUSINESS PARK DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06405-2988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-488-5411
Provider Business Practice Location Address Fax Number:
203-401-6517
Provider Enumeration Date:
11/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DULINA
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
203-573-4803

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  001682 , 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: 0352650002 . This is a "NSC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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