ADVANCED EYECARE PC

Provider Demographics

• NPI: 1790739340
• Name: ADVANCED EYECARE PC
• Entity Type: Organization
• Organization Name: ADVANCED EYECARE PC
• Authorized Official - Title/Position: PRACTICE ADMINISTRATOR
• Authorized Official - Prefix: MS
• Authorized Official - First Name: TRACY
• Authorized Official - Last Name: NILES
• Authorized Official - Phone: 802-447-8700
• Mailing Address - Street 1: 322 DEWEY ST
• Mailing Address - City: BENNINGTON
• Mailing Address - State: VT
• Mailing Address - Zip Code: 05201-2225
• Mailing Address - Country: US
• Mailing Address - Phone: 802-447-8700
• Mailing Address - Fax: 802-447-1500
• Practice Address - Street 1: 322 DEWEY ST
• Practice Address - City: BENNINGTON
• Practice Address - State: VT
• Practice Address - Zip Code: 05201-2225
• Practice Address - Country: US
• Practice Address - Phone: 802-447-8700
• Practice Address - Fax: 802-447-1500
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-05-19
• Last Update Date: 2020-07-21

Provider Licenses

State	License ID	Taxonomies
VT		152W00000X, 207W00000X
MA		207W00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207W00000X	Allopathic & Osteopathic Physicians	Ophthalmology		Group - Multi-Specialty
No	152W00000X	Eye and Vision Services Providers	Optometrist		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MA	110072172A	Medicaid
VT	ADVA318-19924	Other	VTBS
MA	ADVA318-19924	Other	VTBS
MA	M16004	Other	MABS
VT	M16004	Other	MABS
VT	VN0966	Medicaid
VT	1059	Other	CDPHP
MA	200052887	Other	MVP
MA	614906	Other	TUFTS
NY	01794247	Medicaid
VT	1268	Other	HNE
MA	1059	Other	CDPHP
MA	1268	Other	HNE
VT	200052887	Other	MVP
VT	VT0949	Medicaid
VT	614906	Other	TUFTS
VT	VN0949	Medicare PIN
VT	VN0966	Medicare PIN
MA	1059	Other	CDPHP
VT	VT0949	Medicaid
VT	614906	Other	TUFTS
VT	1059	Other	CDPHP
VT	0965940001	Medicare NSC
MA	614906	Other	TUFTS