Provider Demographics
NPI:1831647247
Name:MATTHEW BLONDIN, BLONDIN SHEA EYE CARE
Entity Type:Organization
Organization Name:MATTHEW BLONDIN, BLONDIN SHEA EYE CARE
Other - Org Name:BLONDIN SHEA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BLONDIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:860-489-2781
Mailing Address - Street 1:P.O. BOX 448
Mailing Address - Street 2:379 PROSPECT STREET, SUITE B
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790
Mailing Address - Country:US
Mailing Address - Phone:860-489-2781
Mailing Address - Fax:860-489-9017
Practice Address - Street 1:379 PROSPECT STREET
Practice Address - Street 2:SUITE B
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790
Practice Address - Country:US
Practice Address - Phone:860-489-2781
Practice Address - Fax:860-489-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000845152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004024592Medicaid
CT410000283Medicare PIN