Healthcare Provider Details

I. General information

NPI: 1255439188
Provider Name (Legal Business Name): KILLINGLY EYE CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

IV. Provider business mailing address

25 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

V. Phone/Fax

Practice location:
  • Phone: 860-779-1588
  • Fax: 860-779-1754
Mailing address:
  • Phone: 860-779-1588
  • Fax: 860-779-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number864
License Number StateCT

VII. Legacy identifiers

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

# 1
Identifier52KILLEYECT01
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier4188258
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: DR. JAMES L BOCCUZZI
Title or Position: PRESIDENT
Credential: O.D.
Phone: 860-779-1588