Healthcare Provider Details

I. General information

NPI: 1710904537
Provider Name (Legal Business Name): CONSTITUTION EYE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 WILLARD AVE BUILDING 3
NEWINGTON CT
06111-2650
US

IV. Provider business mailing address

505 WILLARD AVE BUILDING 3
NEWINGTON CT
06111-2650
US

V. Phone/Fax

Practice location:
  • Phone: 860-665-0174
  • Fax: 860-667-2066
Mailing address:
  • Phone: 860-665-0174
  • Fax: 860-667-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KRIS MINEAU
Title or Position: ADMINISTRATOR
Credential:
Phone: 860-665-0174