MEDICARE: EATON EYECARE OF GRANBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2878	CT

General Provider Information

NPI Number	:	1447639349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EATON EYECARE OF GRANBY

Provider Business Mailing Address
First Line	:	71 JOHN OLDS DR APT 208
Second Line	:
City	:	MANCHESTER
State	:	CT
Zip	:	06042-8794
Country	:	US
Telephone Number	:	860-951-6582
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 E GRANBY RD
Second Line	:
City	:	GRANBY
State	:	CT
Zip	:	06035-2201
Country	:	US
Telephone Number	:	860-653-3008
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. DAVID EARL EATON JR.
Credential	:	O.D.
Telephone Number	:	860-951-6582

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/26/2015

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