Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LO-# 715 | CT |
NPI | 1033241997 |
---|---|
Provider Name | Gary Dennis Heins |
First Address | North Haven, CT 06473-1769 |
Second Address | North Haven, CT 06473-1769 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 15/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0648180001 | NSC--NUMBER (01) | CT |
100000715CT-01 | BLUE CROSS PROVIDER (01) | CT |
61-1442432 | FEDERAL TAX (01) | CT |