Provider Demographics
NPI:1235337494
Name:VICKERS EYECARE, INC
Entity Type:Organization
Organization Name:VICKERS EYECARE, INC
Other - Org Name:ADVANCED FAMILY VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-358-3937
Mailing Address - Street 1:9815 HWY 70 WEST, SUITE 102
Mailing Address - Street 2:PO BOX 971
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-0971
Mailing Address - Country:US
Mailing Address - Phone:715-358-3937
Mailing Address - Fax:715-358-7677
Practice Address - Street 1:9815 HWY 70 WEST
Practice Address - Street 2:SUITE 102
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-0971
Practice Address - Country:US
Practice Address - Phone:715-358-3937
Practice Address - Fax:715-358-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2838-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU57933Medicare UPIN
WI47284Medicare ID - Type Unspecified