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General NPI Number Information
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NPI Number | 1538666235
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Entity Type | Organization
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Legal Business Name | MAD RIVER EYE CARE PLLC
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 04/09/2018
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Provider Practice Location Address
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Address Line | 5274 MAIN ST STE 1
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City | WAITSFIELD
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State | VT
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Zip | 05673-4445
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Country | US
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Telephone | 802-730-5167
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Fax |
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Provider Business Mailing Address
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Address Line | 731 WORCESTER LOOP RD
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City | STOWE
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State | VT
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Zip | 05672-4326
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Country | US
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Telephone | 802-730-5167
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. SHANNON HAWKLEY MITCHELL
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Credential | OD
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Telephone | 802-730-5167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 030.0068209
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License Number State | VT
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