Provider Demographics
NPI:1457683955
Name:MOZDEN FAMILY OPTICAL LLC
Entity Type:Organization
Organization Name:MOZDEN FAMILY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ L.O.
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOZDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-889-9887
Mailing Address - Street 1:11 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TAFTVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06380-1407
Mailing Address - Country:US
Mailing Address - Phone:860-889-9887
Mailing Address - Fax:
Practice Address - Street 1:11 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:TAFTVILLE
Practice Address - State:CT
Practice Address - Zip Code:06380-1407
Practice Address - Country:US
Practice Address - Phone:860-889-9887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001598332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTMCD 008025398Medicaid