Provider Demographics
NPI:1972725125
Name:PEDIATRIC EYE CARE LLC
Entity type:Organization
Organization Name:PEDIATRIC EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-458-8300
Mailing Address - Street 1:206 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437
Mailing Address - Country:US
Mailing Address - Phone:203-458-8300
Mailing Address - Fax:
Practice Address - Street 1:206 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-458-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034441174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F66746Medicare UPIN