=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689759052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRICOUNTY VISION ASSOCIATES, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 05/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 WALNUT ST
-----------------------------------------------------
City | WILLIMANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06226-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-423-2565
-----------------------------------------------------
Fax | 860-423-8058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 WALNUT ST
-----------------------------------------------------
City | WILLIMANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06226-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-423-2565
-----------------------------------------------------
Fax | 860-423-8058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. BETH SCHRAMM
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 860-423-2565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 002415
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------