Provider Demographics
NPI:1104465939
Name:WILD APPLE EYE LLC
Entity type:Organization
Organization Name:WILD APPLE EYE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PARADIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-577-2012
Mailing Address - Street 1:54 BOKUM RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1207
Mailing Address - Country:US
Mailing Address - Phone:860-391-3366
Mailing Address - Fax:
Practice Address - Street 1:90 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CENTERBROOK
Practice Address - State:CT
Practice Address - Zip Code:06409-1057
Practice Address - Country:US
Practice Address - Phone:860-767-3206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8073265Medicaid
CTA31568OtherEYEMED
CT139866OtherCTCARE
CT4002760OtherCIGNA
CTP5740240OtherOXFORD
CT12002152OtherHARVARD PILGRIM
1473930OtherWELLCARE