Provider Demographics
NPI:1710290580
Name:PRO EYE INC
Entity Type:Organization
Organization Name:PRO EYE INC
Other - Org Name:PRO EYE ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-872-3348
Mailing Address - Street 1:219 TALCOTTVILLE RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4637
Mailing Address - Country:US
Mailing Address - Phone:860-872-3348
Mailing Address - Fax:860-872-3643
Practice Address - Street 1:219 TALCOTTVILLE RD
Practice Address - Street 2:SUITE #3
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4637
Practice Address - Country:US
Practice Address - Phone:860-872-3348
Practice Address - Fax:860-872-3643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00438912Medicaid
U83550Medicare UPIN