Basic Information
| Provider Information | |||||||||
| NPI: | 1710904537 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSTITUTION EYE SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 WILLARD AVE | ||||||||
| Address2: | BUILDING 3 | ||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606650174 | ||||||||
| FaxNumber: | 8606672066 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 WILLARD AVE | ||||||||
| Address2: | BUILDING 3 | ||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606650174 | ||||||||
| FaxNumber: | 8606672066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | MINEAU | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8606650174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
No ID Information.