Provider Demographics
NPI:1649628793
Name:SIROIS, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:SIROIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06256-1052
Mailing Address - Country:US
Mailing Address - Phone:860-423-5230
Mailing Address - Fax:860-423-5267
Practice Address - Street 1:474 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:NORTH WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06256-1052
Practice Address - Country:US
Practice Address - Phone:860-423-5230
Practice Address - Fax:860-423-5267
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1057156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCT. 1057OtherSTATE LICENSE