Basic Information
| Provider Information | |||||||||
| NPI: | 1720094535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARUTHERS | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OPTICIAN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | AUDREY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PRESTIGE DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064507164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036390311 | ||||||||
| FaxNumber: | 2036391489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 000750 | CT | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.