Healthcare Provider Details

I. General information

NPI: 1780013854
Provider Name (Legal Business Name): THE EYE CARE GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 OLD WATERBURY RD SUITE 202
SOUTHBURY CT
06488-3848
US

IV. Provider business mailing address

1201 W MAIN ST SUITE 200
WATERBURY CT
06708-3105
US

V. Phone/Fax

Practice location:
  • Phone: 203-262-1600
  • Fax: 203-401-6517
Mailing address:
  • Phone: 203-573-4885
  • Fax: 203-401-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number001664
License Number StateCT

VIII. Authorized Official

Name: MS. CHERYL DULINA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 203-573-4803