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General NPI Number Information
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NPI Number | 1174926653
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Entity Type | Organization
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Legal Business Name | CRYSTAL VISION WEST HARTFORD LLC.
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 64 RAYMOND RD SUITE170
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2213
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Country | US
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Telephone | 860-442-0380
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Fax |
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Provider Business Mailing Address
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Address Line | 909 HARTFORD TPKE UNIT D2
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City | WATERFORD
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State | CT
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Zip | 06385-4267
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Country | US
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Telephone | 860-442-0380
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Fax | 860-437-1717
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN MANN
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Credential | O.D
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Telephone | 860-442-0380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 002229
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License Number State | CT
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