Healthcare Provider Details

I. General information

NPI: 1487833513
Provider Name (Legal Business Name): SUFFIELD EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 MOUNTAIN RD
SUFFIELD CT
06078-2091
US

IV. Provider business mailing address

162 MOUNTAIN RD
SUFFIELD CT
06078-2091
US

V. Phone/Fax

Practice location:
  • Phone: 860-668-0266
  • Fax: 860-668-5556
Mailing address:
  • Phone: 860-668-0266
  • Fax: 860-668-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ALEXIS COLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-668-0266