=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467614347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR EYES OF NEW BRITAIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2008
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 198 E MAIN ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06051-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-223-7900
-----------------------------------------------------
Fax | 860-826-7161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 198 E MAIN ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06051-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-223-7900
-----------------------------------------------------
Fax | 860-826-7161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROL ANN SANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-223-7900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 001298
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 001298
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------