=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053459552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APPLE VALLEY VISION CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 01/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 MAIN ST SUITE 1
-----------------------------------------------------
City | ESSEX JUNCTION
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05452-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-879-0256
-----------------------------------------------------
Fax | 802-879-2401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 MAIN ST SUITE 1
-----------------------------------------------------
City | ESSEX JUNCTION
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05452-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-879-0256
-----------------------------------------------------
Fax | 802-879-2401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. JOHN W. ELLISON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 802-879-0256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 030-0000316
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------