Basic Information
| Provider Information | |||||||||
| NPI: | 1497705677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTICARE EYE HEALTH CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
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| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2035962230 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2035962230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | NOLL | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VICE PRES | ||||||||
| AuthorizedOfficialTelephone: | 2035742020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 261QA1903X | 0071 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 004171766 | 05 | CT | MEDICAID | 004002812 | 05 | CT | MEDICAID | 004081353 | 05 | CT | MEDICAID |