Healthcare Provider Details

I. General information

NPI: 1073740437
Provider Name (Legal Business Name): VINEYARD VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 BEACH RD UNIT 30
VINEYARD HAVEN MA
02568-2600
US

IV. Provider business mailing address

PO BOX 519
VINEYARD HAVEN MA
02568-0519
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-3517
  • Fax: 508-696-8570
Mailing address:
  • Phone: 508-693-3517
  • Fax: 508-696-8570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2348
License Number StateMA

VIII. Authorized Official

Name: RYAN P. SHEA
Title or Position: DOCTOR/OWNER
Credential: OD
Phone: 508-693-3517