Provider Demographics
NPI:1477587939
Name:LEIF ERICKSON, OD, LLC
Entity Type:Organization
Organization Name:LEIF ERICKSON, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEIF
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-775-0862
Mailing Address - Street 1:44 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-5031
Mailing Address - Country:US
Mailing Address - Phone:802-775-0862
Mailing Address - Fax:802-747-7714
Practice Address - Street 1:44 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5031
Practice Address - Country:US
Practice Address - Phone:802-775-0862
Practice Address - Fax:802-747-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN3991Medicare PIN
VT6098710002Medicare NSC