Provider Demographics
NPI:1477002525
Name:ROBERT JOHN KISH OPTICS UNLIMITED LLC
Entity Type:Organization
Organization Name:ROBERT JOHN KISH OPTICS UNLIMITED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-448-3937
Mailing Address - Street 1:748 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4273
Mailing Address - Country:US
Mailing Address - Phone:860-448-3937
Mailing Address - Fax:860-449-0343
Practice Address - Street 1:748 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4273
Practice Address - Country:US
Practice Address - Phone:860-448-3937
Practice Address - Fax:860-449-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT797305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service