Healthcare Provider Details

I. General information

NPI: 1144369588
Provider Name (Legal Business Name): EYECARE CENTER OF WATERBURY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 WOLCOTT ST
WATERBURY CT
06705-1342
US

IV. Provider business mailing address

625 WOLCOTT ST
WATERBURY CT
06705-1342
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-8339
  • Fax:
Mailing address:
  • Phone: 203-754-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number000910
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number000910
License Number StateCT

VIII. Authorized Official

Name: DR. JOHN JOSEPH PULASKI
Title or Position: OPTOMETRIST
Credential: OD
Phone: 203-754-8339