Provider Demographics
NPI:1275025207
Name:PADULA FAMILY VISION & SPORTS ENHANCEMENT CENTER, LLC
Entity Type:Organization
Organization Name:PADULA FAMILY VISION & SPORTS ENHANCEMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:PADULA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-453-0617
Mailing Address - Street 1:37 SOUNDVIEW RD STE 1
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2965
Mailing Address - Country:US
Mailing Address - Phone:203-453-0617
Mailing Address - Fax:
Practice Address - Street 1:37 SOUNDVIEW RD STE 1
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2965
Practice Address - Country:US
Practice Address - Phone:203-453-0617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000858152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty