Provider Demographics
NPI:1437248424
Name:THE GUILFORD OPTICAL SHOPPE INC
Entity Type:Organization
Organization Name:THE GUILFORD OPTICAL SHOPPE INC
Other - Org Name:KENNETH N. HEBERT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:F
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-453-6776
Mailing Address - Street 1:115 STATE ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2725
Mailing Address - Country:US
Mailing Address - Phone:203-453-6776
Mailing Address - Fax:
Practice Address - Street 1:115 STATE ST
Practice Address - Street 2:THE GUILFORD OPTICAL SHOPPE INC
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2725
Practice Address - Country:US
Practice Address - Phone:203-453-6776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLO416332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0576470001Medicare NSC