Provider Demographics
NPI:1194124453
Name:EYEDOCARE,CORP
Entity type:Organization
Organization Name:EYEDOCARE,CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-547-6522
Mailing Address - Street 1:12 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1934
Mailing Address - Country:US
Mailing Address - Phone:516-547-6522
Mailing Address - Fax:
Practice Address - Street 1:500 WESTFARMS MALL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2615
Practice Address - Country:US
Practice Address - Phone:860-674-6053
Practice Address - Fax:860-674-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008051371Medicaid
NYF63632Medicare UPIN