Healthcare Provider Details

I. General information

NPI: 1821410747
Provider Name (Legal Business Name): MY EYE SHOPPE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2014
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MAIN AVE
NORWALK CT
06851-1126
US

IV. Provider business mailing address

650 MAIN AVE
NORWALK CT
06851-1126
US

V. Phone/Fax

Practice location:
  • Phone: 203-939-1880
  • Fax:
Mailing address:
  • Phone: 203-939-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number00408
License Number StateCT

VIII. Authorized Official

Name: MICHELLE CLEMENT
Title or Position: MANAGER
Credential:
Phone: 203-939-1880