Provider Demographics
NPI:1689269276
Name:EYE DOC LLC
Entity Type:Organization
Organization Name:EYE DOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-930-9947
Mailing Address - Street 1:20 MESSIER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GROSVENORDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06255-2012
Mailing Address - Country:US
Mailing Address - Phone:860-930-9947
Mailing Address - Fax:
Practice Address - Street 1:371 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1665
Practice Address - Country:US
Practice Address - Phone:774-241-0718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1851845713Medicaid