1083601587 NPI number — NORTHERN VALLEY EYECARE, INC.

Table of content: (NPI 1083601587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083601587 NPI number — NORTHERN VALLEY EYECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN VALLEY EYECARE, INC.
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:
Provider Other Organization Name Type Code:
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:
1083601587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 FISHER POND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT ALBANS
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05478-6058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-524-9561
Provider Business Mailing Address Fax Number:
802-524-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 FISHER POND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ALBANS
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05478-6058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-524-9561
Provider Business Practice Location Address Fax Number:
802-524-6060
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOULERICE
Authorized Official First Name:
GRETA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
802-524-9561

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  328, 140, 263 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1010944 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC6158 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 200000905 . This is a "MVP HEALTH CARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: NORT00007939 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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