Healthcare Provider Details

I. General information

NPI: 1700045515
Provider Name (Legal Business Name): OPTICAL IMAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 DANBURY ROAD
WILTON CT
06897-4315
US

IV. Provider business mailing address

17 DANBURY ROAD
WILTON CT
06897-4315
US

V. Phone/Fax

Practice location:
  • Phone: 203-762-9669
  • Fax: 203-761-1249
Mailing address:
  • Phone: 203-762-9669
  • Fax: 203-761-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number001245
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number00124
License Number StateCT

VIII. Authorized Official

Name: MR. ASHER N WEIN
Title or Position: PRESIDENT
Credential:
Phone: 203-762-9669