Provider Demographics
NPI:1356465785
Name:SHEBOYGAN OPTICAL CO. LLC
Entity Type:Organization
Organization Name:SHEBOYGAN OPTICAL CO. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:920-458-5096
Mailing Address - Street 1:1442 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3061
Mailing Address - Country:US
Mailing Address - Phone:920-458-5096
Mailing Address - Fax:920-451-1085
Practice Address - Street 1:1442 N 31ST ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3061
Practice Address - Country:US
Practice Address - Phone:920-458-5096
Practice Address - Fax:920-451-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0587980001Medicare NSC
WI0587980001Medicare ID - Type Unspecified