Provider Demographics
NPI:1306029616
Name:OPTOMETRIC SERVICES, S.C.
Entity Type:Organization
Organization Name:OPTOMETRIC SERVICES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:SALISBURY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-788-4162
Mailing Address - Street 1:607 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1856
Mailing Address - Country:US
Mailing Address - Phone:920-788-4162
Mailing Address - Fax:920-788-6134
Practice Address - Street 1:607 WILSON ST
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-1856
Practice Address - Country:US
Practice Address - Phone:920-788-4162
Practice Address - Fax:920-788-6134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
100000291OtherWEA
100000291OtherWEA
WI0511120001Medicare NSC
=========010OtherBLUE CROSS BLUE SHIELD
WIDG9939Medicare PIN