Provider Demographics
NPI:1942459615
Name:CONNECTICUT VISION CENTER, LLC
Entity type:Organization
Organization Name:CONNECTICUT VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-469-1012
Mailing Address - Street 1:64 THOMPSON ST STE B104
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-5701
Mailing Address - Country:US
Mailing Address - Phone:203-469-1012
Mailing Address - Fax:203-467-1369
Practice Address - Street 1:64 THOMPSON ST
Practice Address - Street 2:SUITE B104
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-5707
Practice Address - Country:US
Practice Address - Phone:203-469-1012
Practice Address - Fax:203-467-1369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004173598Medicaid
CT1942459615Medicare NSC
CT410000874Medicare PIN
CT1232780001Medicare NSC