Provider Demographics
NPI:1881144079
Name:VINE BROOK EYECARE LLC
Entity type:Organization
Organization Name:VINE BROOK EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:978-578-0491
Mailing Address - Street 1:120 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-2095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 MIDDLESEX TURNPIKE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803
Practice Address - Country:US
Practice Address - Phone:781-238-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty