Provider Demographics
NPI:1861140030
Name:HENDEWICH, EDMOND CHRISTIAN (LO)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:CHRISTIAN
Last Name:HENDEWICH
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HIGH MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2133
Mailing Address - Country:US
Mailing Address - Phone:860-221-4466
Mailing Address - Fax:
Practice Address - Street 1:599 FARMINGTON AVE STE 201
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2356
Practice Address - Country:US
Practice Address - Phone:860-837-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001424156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician