1487710539 NPI number — I C 20 20 EAU CLAIRE INC

Table of content: (NPI 1487710539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487710539 NPI number — I C 20 20 EAU CLAIRE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
I C 20 20 EAU CLAIRE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STERLING OPTICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487710539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4054 COMMONWEALTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-833-1220
Provider Business Mailing Address Fax Number:
715-833-1297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4054 COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-9000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-833-1220
Provider Business Practice Location Address Fax Number:
715-833-1297
Provider Enumeration Date:
12/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DELAKIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER MANAGER
Authorized Official Telephone Number:
715-833-1220

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  2275035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38711700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".