1235337494 NPI number — VICKERS EYECARE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235337494 NPI number — VICKERS EYECARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKERS EYECARE, 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:
Provider Other Organization Name Type Code:
6
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:
1235337494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9815 HWY 70 WEST, SUITE 102
Provider Second Line Business Mailing Address:
PO BOX 971
Provider Business Mailing Address City Name:
MINOCQUA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54548-0971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-358-3937
Provider Business Mailing Address Fax Number:
715-358-7677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9815 HWY 70 WEST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MINOCQUA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54548-0971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-358-3937
Provider Business Practice Location Address Fax Number:
715-358-7677
Provider Enumeration Date:
07/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VICKERS
Authorized Official First Name:
C
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
715-358-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2838-035 , 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)





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