Provider Demographics
NPI:1932296225
Name:EYEBALL OPTICAL INC
Entity Type:Organization
Organization Name:EYEBALL OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:860-876-6156
Mailing Address - Street 1:458 TALCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4052
Mailing Address - Country:US
Mailing Address - Phone:860-875-6156
Mailing Address - Fax:860-871-3822
Practice Address - Street 1:458 TALCOTTVILLE RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4052
Practice Address - Country:US
Practice Address - Phone:860-875-6156
Practice Address - Fax:860-871-3822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1167332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0598060001Medicare NSC