Healthcare Provider Details

I. General information

NPI: 1083601587
Provider Name (Legal Business Name): NORTHERN VALLEY EYECARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/11/2022
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 FISHER POND RD
SAINT ALBANS VT
05478-6058
US

IV. Provider business mailing address

128 FISHER POND RD
SAINT ALBANS VT
05478-6058
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-9561
  • Fax: 802-524-6060
Mailing address:
  • Phone: 802-524-9561
  • Fax: 802-524-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number328, 140, 263
License Number StateVT

VIII. Authorized Official

Name: MS. GRETA M. BOULERICE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 802-524-9561