MEDICARE: ETHAN ALLEN OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0280000210	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629254990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHAN ALLEN OPTICAL

Provider Business Mailing Address
First Line	:	1127 NORTH AVE STE 34
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05408-2756
Country	:	US
Telephone Number	:	802-658-6700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 NORTH AVE STE 34
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05408-2756
Country	:	US
Telephone Number	:	802-658-6700
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN
Name	:	CHRISTOPHER THOMAS MURTHA
Credential	:
Telephone Number	:	802-658-6700

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	01/16/2008

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