Provider Demographics
NPI:1134315427
Name:SOUTHINGTON OPTOMETRIC CARE, LLC
Entity Type:Organization
Organization Name:SOUTHINGTON OPTOMETRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-583-5357
Mailing Address - Street 1:58 MAIN ST
Mailing Address - Street 2:PO BOX 52
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-5121
Mailing Address - Country:US
Mailing Address - Phone:860-583-5357
Mailing Address - Fax:860-621-4911
Practice Address - Street 1:58 MAIN ST
Practice Address - Street 2:
Practice Address - City:TERRYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06786-5121
Practice Address - Country:US
Practice Address - Phone:860-583-5357
Practice Address - Fax:860-621-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004199354Medicaid
CT004199354Medicaid
CT1294950001Medicare NSC