Healthcare Provider Details

I. General information

NPI: 1962631366
Provider Name (Legal Business Name): NORWICH OPHTHALMOLOGY OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 NORWICH AVE
COLCHESTER CT
06415-1256
US

IV. Provider business mailing address

79 WAWECUS ST
NORWICH CT
06360-2160
US

V. Phone/Fax

Practice location:
  • Phone: 860-537-4644
  • Fax: 860-537-2501
Mailing address:
  • Phone: 860-886-0161
  • Fax: 860-889-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number001624
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number000433
License Number StateCT

VIII. Authorized Official

Name: DR. JEFFREY A. HERTZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 860-886-0161