MEDICARE: RATTANA MEUANETHONGCHANH L.O.

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	156FX1800X	Optician	001597	CT

General Provider Information

NPI Number	:	1578799904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RATTANA MEUANETHONGCHANH L.O.

Provider Business Mailing Address
First Line	:	69 PROSPECT HILL RD
Second Line	:
City	:	EAST WINDSOR
State	:	CT
Zip	:	06088-3600
Country	:	US
Telephone Number	:	860-623-7910
Fax Number	:	860-627-6433

Provider Business Practice Location Address
First Line	:	69 PROSPECT HILL RD
Second Line	:
City	:	EAST WINDSOR
State	:	CT
Zip	:	06088-3600
Country	:	US
Telephone Number	:	860-623-7910
Fax Number	:	860-627-6433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2009
Last Update Date	:	05/29/2009

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