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General NPI Number Information
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NPI Number | 1336301597
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Entity Type | Organization
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Legal Business Name | SIDET SOU, OD, LLC
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Dates
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Enumeration Date | 06/30/2008
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 69 PAVILION DR
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City | MANCHESTER
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State | CT
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Zip | 06042-8702
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Country | US
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Telephone | 860-644-9439
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Fax |
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Provider Business Mailing Address
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Address Line | 69 PAVILION DR
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City | MANCHESTER
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State | CT
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Zip | 06042-8702
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Country | US
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Telephone | 860-644-9439
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. SIDET SOU
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Credential | O.D.
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Telephone | 860-644-9439
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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 | CT002732
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License Number State | CT
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