1457459836 NPI number — ANTIGO EYE CARE CENTER

Table of content: (NPI 1457459836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457459836 NPI number — ANTIGO EYE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTIGO EYE CARE CENTER
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:
Provider Other Organization Name Type Code:
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:
1457459836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
810 5TH AVE
Provider Second Line Business Mailing Address:
P O BOX 628
Provider Business Mailing Address City Name:
ANTIGO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54409-1937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-623-3620
Provider Business Mailing Address Fax Number:
715-623-3333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTIGO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54409-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-623-3620
Provider Business Practice Location Address Fax Number:
715-623-3333
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARTLETTE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
715-623-3620

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T61453 , 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: 38708600-38553700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".