Provider Demographics
NPI:1962170035
Name:VILLACIS EYECARE IV, LLC
Entity type:Organization
Organization Name:VILLACIS EYECARE IV, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:CESAR
Authorized Official - Last Name:VILLACIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-887-1265
Mailing Address - Street 1:20 WATERSIDE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3090
Mailing Address - Country:US
Mailing Address - Phone:860-674-0307
Mailing Address - Fax:
Practice Address - Street 1:20 WATERSIDE DR STE 102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3090
Practice Address - Country:US
Practice Address - Phone:860-674-0307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-02
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty