Provider Demographics
NPI:1922031012
Name:MOULTONS SPECTACLE SHOPPE
Entity Type:Organization
Organization Name:MOULTONS SPECTACLE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:802-442-8002
Mailing Address - Street 1:463 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201
Mailing Address - Country:US
Mailing Address - Phone:802-442-8002
Mailing Address - Fax:802-447-2957
Practice Address - Street 1:463 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2141
Practice Address - Country:US
Practice Address - Phone:802-442-8002
Practice Address - Fax:802-447-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0280000139156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0821430002Medicare ID - Type Unspecified