Healthcare Provider Details

I. General information

NPI: 1639614332
Provider Name (Legal Business Name): WATERBURY EYE CARE CENTER, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 S MAIN ST
WATERBURY VT
05676-1573
US

IV. Provider business mailing address

83 S MAIN ST
WATERBURY VT
05676-1573
US

V. Phone/Fax

Practice location:
  • Phone: 802-244-1360
  • Fax:
Mailing address:
  • Phone: 802-244-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: RANDIE J WILLAND
Title or Position: SOLE MBR
Credential: O.D.
Phone: 802-279-8033