=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104829100
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES ROBERT CYR O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 02/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5399 WILLISTON RD STE 102
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05495-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-864-5428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 POKER HILL RD
-----------------------------------------------------
City | UNDERHILL
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05489-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-899-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 228
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 030-0000228
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------