Provider Demographics
NPI:1679107411
Name:OPTIMYSTIC LLC
Entity type:Organization
Organization Name:OPTIMYSTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-536-1313
Mailing Address - Street 1:12 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2809
Mailing Address - Country:US
Mailing Address - Phone:860-536-1313
Mailing Address - Fax:860-572-7770
Practice Address - Street 1:12 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2809
Practice Address - Country:US
Practice Address - Phone:860-536-1313
Practice Address - Fax:860-572-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty