Provider Demographics
NPI:1104878206
Name:WHITE RIVER FAMILY EYECARE, PC
Entity type:Organization
Organization Name:WHITE RIVER FAMILY EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-295-4887
Mailing Address - Street 1:587 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-8031
Mailing Address - Country:US
Mailing Address - Phone:802-295-4887
Mailing Address - Fax:802-295-5896
Practice Address - Street 1:587 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-8031
Practice Address - Country:US
Practice Address - Phone:802-295-4887
Practice Address - Fax:802-295-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT030-0000220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009878Medicaid
VT4861170001Medicare NSC
VTVN3226Medicare PIN