Provider Demographics
NPI:1164933115
Name:SEYMOUR VISION LLC
Entity Type:Organization
Organization Name:SEYMOUR VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-318-3451
Mailing Address - Street 1:343 BEACH ST APT 506
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-6172
Mailing Address - Country:US
Mailing Address - Phone:707-318-3451
Mailing Address - Fax:
Practice Address - Street 1:343 BEACH ST APT 506
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-6172
Practice Address - Country:US
Practice Address - Phone:707-318-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008060451Medicaid