1336216472 NPI number — KIVLIN EYE CLINIC SC

Table of content: (NPI 1336216472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336216472 NPI number — KIVLIN EYE CLINIC SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIVLIN EYE CLINIC SC
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:
1336216472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2303 SCHNEIDER AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENOMONIE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54751-7005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-235-3838
Provider Business Mailing Address Fax Number:
715-235-3846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2303 SCHNEIDER AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENOMONIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54751-7005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-235-3838
Provider Business Practice Location Address Fax Number:
715-235-3846
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIVLIN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER OPTOMETRIST
Authorized Official Telephone Number:
715-235-3838

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1539035 , 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: 0523040001 . This is a "DMERC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38564800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com