Provider Demographics
NPI:1912068925
Name:COBBS OPTICAL SHOPPE LTD
Entity Type:Organization
Organization Name:COBBS OPTICAL SHOPPE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:COBB
Authorized Official - Suffix:JR
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:860-599-3882
Mailing Address - Street 1:804 STONINGTON RD
Mailing Address - Street 2:
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2510
Mailing Address - Country:US
Mailing Address - Phone:860-599-3882
Mailing Address - Fax:860-599-8680
Practice Address - Street 1:804 STONINGTON RD
Practice Address - Street 2:
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-2510
Practice Address - Country:US
Practice Address - Phone:860-599-3882
Practice Address - Fax:860-599-8680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT100000649CT01OtherANTHEM BLUE CROSS BLUE SH
CT0139650001Medicare ID - Type Unspecified