Healthcare Provider Details

I. General information

NPI: 1265405203
Provider Name (Legal Business Name): BLOOMFIELD EYE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 NORTHWESTERN DR
BLOOMFIELD CT
06002-3444
US

IV. Provider business mailing address

1A BURTON HILLS BLVD # L&C
NASHVILLE TN
37215-6187
US

V. Phone/Fax

Practice location:
  • Phone: 608-243-2020
  • Fax: 860-243-5190
Mailing address:
  • Phone: 615-240-3820
  • Fax: 615-234-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0271
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier004218716
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: MR. JEFFREY SNODGRASS
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283