Provider Demographics
NPI:1124117973
Name:EYECARE OF VERMONT, PLC
Entity type:Organization
Organization Name:EYECARE OF VERMONT, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:ERIKSSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-878-5509
Mailing Address - Street 1:230 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-8352
Mailing Address - Country:US
Mailing Address - Phone:802-658-3330
Mailing Address - Fax:802-658-7464
Practice Address - Street 1:230 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8352
Practice Address - Country:US
Practice Address - Phone:802-658-3330
Practice Address - Fax:802-658-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000265152WL0500X
VT030-0000293152WL0500X
VT030-0000156152W00000X
VT030-0000338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTCG0391OtherRAILROAD MEDICARE
VTOVN2193Medicaid
VT39218OtherBLUECROSS/BLUESHIELD
VTOVN2193Medicaid
VN2193Medicare PIN
VTCG0391OtherRAILROAD MEDICARE
VTVN2193Medicare UPIN
VTU82347Medicare UPIN
VT39218OtherBLUECROSS/BLUESHIELD
VTV07512Medicare UPIN
VT1166180003Medicare NSC
VT1166180001Medicare NSC