Provider Demographics
NPI:1861807059
Name:BRADFORD OPTICAL, PLC
Entity type:Organization
Organization Name:BRADFORD OPTICAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-222-4543
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-0325
Mailing Address - Country:US
Mailing Address - Phone:802-222-4543
Mailing Address - Fax:802-222-4503
Practice Address - Street 1:331 UPPER PLN
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033-9207
Practice Address - Country:US
Practice Address - Phone:802-222-4543
Practice Address - Fax:802-222-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1023472Medicaid
VTY100159753Medicare PIN