Provider Demographics
NPI:1780862888
Name:CHARLES BONELLI
Entity Type:Organization
Organization Name:CHARLES BONELLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-693-2289
Mailing Address - Street 1:220 ALBANY TPKE
Mailing Address - Street 2:PO BOX 14
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2520
Mailing Address - Country:US
Mailing Address - Phone:860-693-2289
Mailing Address - Fax:860-693-1835
Practice Address - Street 1:220 ALBANY TPKE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2520
Practice Address - Country:US
Practice Address - Phone:860-693-2289
Practice Address - Fax:860-693-1835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004024170Medicaid
CT410000246Medicare PIN
CT004024170Medicaid