=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710361126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVON EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 07/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43 W MAIN ST
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-4219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-246-3082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 376 DEMING ST
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | HARNEET DHILLON MCDERMOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-246-3082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2833
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------