Provider Demographics
NPI:1134142243
Name:WINCKLER VISION CENTER, INC.
Entity Type:Organization
Organization Name:WINCKLER VISION CENTER, INC.
Other - Org Name:PINE RIDGE VISION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:INSURANCE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:WINCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-867-2772
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:HWY 18
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-0399
Mailing Address - Country:US
Mailing Address - Phone:605-867-2772
Mailing Address - Fax:605-867-2320
Practice Address - Street 1:207 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-3184
Practice Address - Country:US
Practice Address - Phone:605-867-2772
Practice Address - Fax:605-867-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993076OtherWELLMARK BCBS
SD4993078OtherWELLMARK BCBS
SD9200333Medicaid
SD9202143Medicaid
SD9280200Medicaid
SD4993075OtherWELLMARK BCBS
SD4993077OtherWELLMARK BCBS
SD9203683Medicaid
SD9202143Medicaid
SDS101740Medicare PIN
SDS101738Medicare PIN
SD4993077OtherWELLMARK BCBS
V11678Medicare UPIN
SD0324130005Medicare NSC
SD4993075OtherWELLMARK BCBS
E52883Medicare UPIN