Provider Demographics
NPI:1083089882
Name:PROGRESSIVE FAMILY EYECARE LLC
Entity Type:Organization
Organization Name:PROGRESSIVE FAMILY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-873-2020
Mailing Address - Street 1:105 KINGS LYNN RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1999
Mailing Address - Country:US
Mailing Address - Phone:608-873-2020
Mailing Address - Fax:
Practice Address - Street 1:105 KINGS LYNN RD
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1999
Practice Address - Country:US
Practice Address - Phone:608-873-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3075-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty