Provider Demographics
NPI:1083808802
Name:CARDINAL FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:CARDINAL FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:VERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-861-5253
Mailing Address - Street 1:102 E STANLEY ST
Mailing Address - Street 2:PO BOX 468
Mailing Address - City:THORP
Mailing Address - State:WI
Mailing Address - Zip Code:54771-9649
Mailing Address - Country:US
Mailing Address - Phone:715-669-5631
Mailing Address - Fax:715-669-5353
Practice Address - Street 1:102 E STANLEY ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-9649
Practice Address - Country:US
Practice Address - Phone:715-669-5631
Practice Address - Fax:715-669-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3083-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38726700Medicaid
WI000047998Medicare PIN
WI38726700Medicaid