Provider Demographics
NPI:1073710968
Name:MEDICAL EYE CLINIC OF EAU CLAIRE
Entity Type:Organization
Organization Name:MEDICAL EYE CLINIC OF EAU CLAIRE
Other - Org Name:EAU CLAIRE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-834-5644
Mailing Address - Street 1:2715 DAMON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2634
Mailing Address - Country:US
Mailing Address - Phone:715-834-5644
Mailing Address - Fax:715-834-5674
Practice Address - Street 1:2715 DAMON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2634
Practice Address - Country:US
Practice Address - Phone:715-834-5644
Practice Address - Fax:715-834-5674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17337332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38444400Medicaid
WI38444400Medicaid