Basic Information
| Provider Information | |||||||||
| NPI: | 1073939302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BIRCHWOOD OPTICAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 546 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064506600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032352511 | ||||||||
| FaxNumber: | 2036390809 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHESHIRE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064102548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032713103 | ||||||||
| FaxNumber: | 2032721786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2014 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2032352511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED EYE PHYSICIANS | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.