Provider Demographics
NPI:1649392259
Name:CRYSTAL VISION BY DRS. OF OPTOMERTRY
Entity Type:Organization
Organization Name:CRYSTAL VISION BY DRS. OF OPTOMERTRY
Other - Org Name:STOWE EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-253-7201
Mailing Address - Street 1:1878 MOUNTAIN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-4775
Mailing Address - Country:US
Mailing Address - Phone:802-253-7201
Mailing Address - Fax:802-253-7522
Practice Address - Street 1:1878 MOUNTAIN RD STE 2
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4775
Practice Address - Country:US
Practice Address - Phone:802-253-7201
Practice Address - Fax:802-253-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000300332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012379Medicaid
VT1922077916OtherNPI
VT1922077916OtherNPI
VT1012379Medicaid