1962485615 NPI number — EYE CLINIC OF WISCONSIN, S.C.

Table of content: (NPI 1962485615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962485615 NPI number — EYE CLINIC OF WISCONSIN, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CLINIC OF WISCONSIN, S.C.
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:
1962485615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54402-0689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-261-8500
Provider Business Mailing Address Fax Number:
715-261-8667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 STANLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEVENS POINT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54481-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-344-6544
Provider Business Practice Location Address Fax Number:
715-344-7391
Provider Enumeration Date:
11/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
715-261-8500

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , 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: 32667800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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