1083988620 NPI number — ULTIMATE EYE CARE LLC

Table of content: (NPI 1083988620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083988620 NPI number — ULTIMATE EYE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ULTIMATE EYE CARE LLC
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:
1083988620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 W TOWNE MALL
Provider Second Line Business Mailing Address:
SEARS OPTICAL
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53719-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-829-3041
Provider Business Mailing Address Fax Number:
608-833-0754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53 W TOWNE MALL
Provider Second Line Business Practice Location Address:
SEARS OPTICAL
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-829-3041
Provider Business Practice Location Address Fax Number:
608-833-0754
Provider Enumeration Date:
02/29/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JUN
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
773-495-8074

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  324735 , 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)