Provider Demographics
NPI:1043383755
Name:STINE EYE CENTER, LLC
Entity Type:Organization
Organization Name:STINE EYE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:STINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-241-2020
Mailing Address - Street 1:4009 COMMUNITY CENTER DRIVE
Mailing Address - Street 2:#100
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2264
Mailing Address - Country:US
Mailing Address - Phone:715-241-2020
Mailing Address - Fax:715-241-9827
Practice Address - Street 1:4009 COMMUNITY CENTER DRIVE
Practice Address - Street 2:#100
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476
Practice Address - Country:US
Practice Address - Phone:715-241-2020
Practice Address - Fax:715-241-9827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1909035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3976070001Medicare NSC
WI000039075Medicare ID - Type Unspecified