1811612252 NPI number — DOC EYE LLC

Table of content: (NPI 1811612252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811612252 NPI number — DOC EYE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOC 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:
1811612252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 AVALON PINES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11727-5151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-909-6805
Provider Business Mailing Address Fax Number:
518-217-6004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 WATERFORD PKWY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06385-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-215-4009
Provider Business Practice Location Address Fax Number:
518-217-6004
Provider Enumeration Date:
10/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER / MANAGER
Authorized Official Telephone Number:
860-215-4009

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: 008114807 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com