Provider Demographics
NPI:1225307242
Name:MINOCQUA OPTICAL & WELLNESS LLC
Entity Type:Organization
Organization Name:MINOCQUA OPTICAL & WELLNESS LLC
Other - Org Name:DBA TOMAHAWK EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-224-2200
Mailing Address - Street 1:1334 N 4TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-2106
Mailing Address - Country:US
Mailing Address - Phone:715-224-2200
Mailing Address - Fax:419-858-9769
Practice Address - Street 1:1334 N. 4TH STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2137
Practice Address - Country:US
Practice Address - Phone:715-224-2200
Practice Address - Fax:419-858-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI420969Medicaid