1902100795 NPI number — VISION SOURCE OF AMHERST AND GREENFIELD

Table of content: (NPI 1902100795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902100795 NPI number — VISION SOURCE OF AMHERST AND GREENFIELD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION SOURCE OF AMHERST AND GREENFIELD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NONE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902100795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
489 BERNARDSTON RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01301-1238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-772-2571
Provider Business Mailing Address Fax Number:
413-772-2266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
489 BERNARDSTON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01301-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-772-2571
Provider Business Practice Location Address Fax Number:
413-772-2266
Provider Enumeration Date:
01/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WADMAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
WINFIELD
Authorized Official Title or Position:
OPTOMETRIST/PRESIDENT
Authorized Official Telephone Number:
413-772-2571

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3258 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 17524 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 409258 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y70858 . This is a "BC/BS OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000021735 . This is a "HEALTHNET BOSTON MEDICAL" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0353787 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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