Provider Demographics
NPI:1578799904
Name:MEUANETHONGCHANH, RATTANA (LO)
Entity Type:Individual
Prefix:
First Name:RATTANA
Middle Name:
Last Name:MEUANETHONGCHANH
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-3600
Mailing Address - Country:US
Mailing Address - Phone:860-623-7910
Mailing Address - Fax:860-627-6433
Practice Address - Street 1:69 PROSPECT HILL RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-3600
Practice Address - Country:US
Practice Address - Phone:860-623-7910
Practice Address - Fax:860-627-6433
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001597156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0630780321Medicare PIN