Provider Demographics
NPI:1487788634
Name:PLAINVILLE OPTICAL
Entity type:Organization
Organization Name:PLAINVILLE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & LICENSED OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-793-9378
Mailing Address - Street 1:28 EAST ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2309
Mailing Address - Country:US
Mailing Address - Phone:860-793-9378
Mailing Address - Fax:860-793-2494
Practice Address - Street 1:28 EAST ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2309
Practice Address - Country:US
Practice Address - Phone:860-793-9378
Practice Address - Fax:860-793-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001471156FX1800X
CTCT1106332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V5403OtherHEALTHNET
CT004098556Medicaid
CT720325OtherCONNECTICARE
CT090001012CT01OtherANTHEM BCBS