Provider Demographics
NPI:1083601587
Name:NORTHERN VALLEY EYECARE, INC.
Entity Type:Organization
Organization Name:NORTHERN VALLEY EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOULERICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-524-9561
Mailing Address - Street 1:128 FISHER POND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-6058
Mailing Address - Country:US
Mailing Address - Phone:802-524-9561
Mailing Address - Fax:802-524-6060
Practice Address - Street 1:128 FISHER POND RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-6058
Practice Address - Country:US
Practice Address - Phone:802-524-9561
Practice Address - Fax:802-524-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT328, 140, 263152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010944Medicaid
VTDC6158OtherRAILROAD MEDICARE
VT200000905OtherMVP HEALTH CARE
VTNORT00007939OtherBLUE CROSS/BLUE SHIELD
VT5372850001Medicare NSC
VT200000905OtherMVP HEALTH CARE