Provider Demographics
NPI:1609929983
Name:WALLINGFORD OPTICAL, LLC
Entity Type:Organization
Organization Name:WALLINGFORD OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:COMEAU
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:203-265-1541
Mailing Address - Street 1:58 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4112
Mailing Address - Country:US
Mailing Address - Phone:203-265-1541
Mailing Address - Fax:
Practice Address - Street 1:58 CENTER ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4112
Practice Address - Country:US
Practice Address - Phone:203-265-1541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1294332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT100001294CT02OtherBC
CT51051OtherDAVIS VISION
CTCT1294OtherEYEMED
CT5373650001Medicare ID - Type Unspecified