Provider Demographics
NPI:1326568502
Name:SOUTHEAST CONNECTICUT EYE CARE, LLC
Entity Type:Organization
Organization Name:SOUTHEAST CONNECTICUT EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BURKE
Authorized Official - Last Name:CRANMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-373-4148
Mailing Address - Street 1:12 CASE ST STE 215
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2222
Mailing Address - Country:US
Mailing Address - Phone:860-373-4148
Mailing Address - Fax:860-661-0180
Practice Address - Street 1:1041 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4211
Practice Address - Country:US
Practice Address - Phone:860-373-4148
Practice Address - Fax:860-661-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001443556Medicaid