=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356692214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE FAMILY EYECARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2012
-----------------------------------------------------
Last Update Date | 10/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 238G TOLLAND TPKE
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-281-1501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 ELLSWORTH CIR
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-644-1912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. GINA LIPPI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 860-644-1912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2546
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------