Basic Information
| Provider Information | |||||||||
| NPI: | 1689346884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REFOCUS EYE HEALTH OF CENTRAL CONNECTICUT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 GRANDVIEW AVE STE B | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2880 OLD DIXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032486365 | ||||||||
| FaxNumber: | 2032812742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | DOMAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2035742020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.