Provider Demographics
NPI:1255477402
Name:ANDERSON VISION CENTER, LTD.
Entity Type:Organization
Organization Name:ANDERSON VISION CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BREY
Authorized Official - Suffix:
Authorized Official - Credentials:BBA
Authorized Official - Phone:920-235-8880
Mailing Address - Street 1:461 N WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7812
Mailing Address - Country:US
Mailing Address - Phone:920-235-8880
Mailing Address - Fax:920-235-4906
Practice Address - Street 1:461 N WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7812
Practice Address - Country:US
Practice Address - Phone:920-235-8880
Practice Address - Fax:920-235-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38521800Medicaid
WI38521800Medicaid