Provider Demographics
NPI:1538666235
Name:MAD RIVER EYE CARE PLLC
Entity Type:Organization
Organization Name:MAD RIVER EYE CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:HAWKLEY
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-730-5167
Mailing Address - Street 1:731 WORCESTER LOOP RD
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-4326
Mailing Address - Country:US
Mailing Address - Phone:802-730-5167
Mailing Address - Fax:
Practice Address - Street 1:5274 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-4445
Practice Address - Country:US
Practice Address - Phone:802-730-5167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0068209152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty