Provider Demographics
NPI:1215376967
Name:4D OPTOMETRY, LLC
Entity Type:Organization
Organization Name:4D OPTOMETRY, LLC
Other - Org Name:4D VISION GYM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OD
Authorized Official - Phone:860-632-8243
Mailing Address - Street 1:181 SHUNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1143
Mailing Address - Country:US
Mailing Address - Phone:860-632-8423
Mailing Address - Fax:
Practice Address - Street 1:181 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-1143
Practice Address - Country:US
Practice Address - Phone:860-632-8423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2779152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11999461OtherCAQH