Provider Demographics
NPI:1801081104
Name:FAMILY EYECARE AND CONTACT LENS CENTER LLC
Entity type:Organization
Organization Name:FAMILY EYECARE AND CONTACT LENS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHASSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-635-6149
Mailing Address - Street 1:160 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416
Mailing Address - Country:US
Mailing Address - Phone:860-635-6149
Mailing Address - Fax:860-632-1401
Practice Address - Street 1:160 WEST ST
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416
Practice Address - Country:US
Practice Address - Phone:860-635-6149
Practice Address - Fax:860-632-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT04047908Medicaid
CT0515320001Medicare NSC
CT04047908Medicaid
CTU02975Medicare UPIN
CT490000125Medicare PIN