Provider Demographics
NPI:1801330691
Name:PREMIER EYECARE OF MERIDEN LLC.
Entity type:Organization
Organization Name:PREMIER EYECARE OF MERIDEN LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIEMBOB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-235-4462
Mailing Address - Street 1:35 PLEASANT ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7596
Mailing Address - Country:US
Mailing Address - Phone:203-235-4462
Mailing Address - Fax:203-238-4436
Practice Address - Street 1:35 PLEASANT ST STE 2C
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7596
Practice Address - Country:US
Practice Address - Phone:203-235-4462
Practice Address - Fax:203-238-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410000997Medicare UPIN