Provider Demographics
NPI:1306838487
Name:CHIPPEWA VALLEY EYE CLINIC LTD
Entity Type:Organization
Organization Name:CHIPPEWA VALLEY EYE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COAD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-834-8471
Mailing Address - Street 1:2715 DAMON ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2634
Mailing Address - Country:US
Mailing Address - Phone:715-834-8471
Mailing Address - Fax:715-834-0373
Practice Address - Street 1:2715 DAMON ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2634
Practice Address - Country:US
Practice Address - Phone:715-834-8471
Practice Address - Fax:715-834-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32671200Medicaid
WI38721500Medicaid
WI38721500Medicaid
WI32671200Medicaid