Provider Demographics
NPI:1033197397
Name:1 VISION S.C.
Entity Type:Organization
Organization Name:1 VISION S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D. - PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-526-3163
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-0513
Mailing Address - Country:US
Mailing Address - Phone:715-526-3163
Mailing Address - Fax:715-526-4019
Practice Address - Street 1:150A COUNTY RD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-526-3163
Practice Address - Fax:715-526-4019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI410033786OtherRAILROAD MEDICARE
WI38578000Medicaid
WI000087510Medicare ID - Type Unspecified
WI410033786OtherRAILROAD MEDICARE
T83426Medicare UPIN