MEDICARE: THE EYEGLASS LASS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	001744	CT

General Provider Information

NPI Number	:	1083020689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EYEGLASS LASS LLC

Provider Business Mailing Address
First Line	:	277 STATE ST
Second Line	:
City	:	NEW LONDON
State	:	CT
Zip	:	06320-6312
Country	:	US
Telephone Number	:	860-574-9196
Fax Number	:

Provider Business Practice Location Address
First Line	:	277 STATE ST
Second Line	:
City	:	NEW LONDON
State	:	CT
Zip	:	06320-6312
Country	:	US
Telephone Number	:	860-574-9196
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LICENSED OPTICIAN
Name	:	SIOBHAN BURNS
Credential	:
Telephone Number	:	860-501-0611

Provider Enumeration Date	:	07/03/2014
Last Update Date	:	07/03/2014

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