=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518562974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARVEL LEE RENEE BLANCO LO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2020
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 S MAIN ST STE 103
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-236-9004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 BIRCHWOOD DR
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06052-1574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-736-4438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1701
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------