Provider Demographics
NPI:1174653133
Name:ST CROIX FALLS EYE ASSOCIATES
Entity Type:Organization
Organization Name:ST CROIX FALLS EYE ASSOCIATES
Other - Org Name:GRANTSBURG EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-483-3259
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-0767
Mailing Address - Country:US
Mailing Address - Phone:715-483-3259
Mailing Address - Fax:608-571-0088
Practice Address - Street 1:617 S PINE ST
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7935
Practice Address - Country:US
Practice Address - Phone:715-463-2370
Practice Address - Fax:608-571-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2608-035152W00000X
WI2589-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5173080001Medicare NSC
000049065Medicare PIN