=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518647676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLASTONBURY EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2377 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-633-7889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2377 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-633-7889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN NEDELCU
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 860-633-7889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------