Provider Demographics
NPI:1073740437
Name:VINEYARD VISION CARE LLC
Entity type:Organization
Organization Name:VINEYARD VISION CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-693-3517
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0519
Mailing Address - Country:US
Mailing Address - Phone:508-693-3517
Mailing Address - Fax:508-696-8570
Practice Address - Street 1:79 BEACH RD UNIT 30
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-2600
Practice Address - Country:US
Practice Address - Phone:508-693-3517
Practice Address - Fax:508-696-8570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2348332H00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW20518OtherBLUE CROSS AND BLUE SHIELD OF MA
MA110085992AMedicaid
MAW20518OtherBLUE CROSS AND BLUE SHIELD OF MA
MA0013372Medicare PIN