=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386673648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN PAUL COURTEMANCHE O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 N MAIN ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-4083
-----------------------------------------------------
Fax | 860-647-1733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 NORTH MAIN ST.
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-4083
-----------------------------------------------------
Fax | 860-647-1733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 002567
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------