Provider Demographics
NPI:1255465738
Name:PARK PLACE OPTICAL, LTD
Entity Type:Organization
Organization Name:PARK PLACE OPTICAL, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:VRABEC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-739-8235
Mailing Address - Street 1:21 PARK PL
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8872
Mailing Address - Country:US
Mailing Address - Phone:920-739-8235
Mailing Address - Fax:920-749-8095
Practice Address - Street 1:21 PARK PL
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8872
Practice Address - Country:US
Practice Address - Phone:920-739-8235
Practice Address - Fax:920-749-8095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38424500Medicaid
WI38424500Medicaid