Basic Information
| Provider Information | |||||||||
| NPI: | 1770870164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYEQ VISION THERAPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 DW HWY | ||||||||
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| City: | MERRIMACK | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030544143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036446100 | ||||||||
| FaxNumber: | 6034241147 | ||||||||
| Practice Location | |||||||||
| Address1: | 2075 S WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031032305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036446100 | ||||||||
| FaxNumber: | 6034241147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHAUVETTE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6036446100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 550 | NH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.