Provider Demographics
NPI:1821148230
Name:NEW HAVEN OPTICAL, LLC
Entity Type:Organization
Organization Name:NEW HAVEN OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:I
Authorized Official - Credentials:OD
Authorized Official - Phone:260-749-0407
Mailing Address - Street 1:1318 MINNICH RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-2052
Mailing Address - Country:US
Mailing Address - Phone:260-749-0407
Mailing Address - Fax:260-749-9818
Practice Address - Street 1:1318 MINNICH RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2052
Practice Address - Country:US
Practice Address - Phone:260-749-0407
Practice Address - Fax:260-749-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002262B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5612520001Medicare NSC
IN258690Medicare PIN
INU28720Medicare UPIN