Provider Demographics
NPI:1376718536
Name:FAMILY VISION & CONTACT LENS CTRS SC
Entity Type:Organization
Organization Name:FAMILY VISION & CONTACT LENS CTRS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:FAIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-763-0117
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:309 MCHENRY ST
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105
Mailing Address - Country:US
Mailing Address - Phone:262-763-0117
Mailing Address - Fax:262-763-0119
Practice Address - Street 1:920 GREENWALD CT
Practice Address - Street 2:SUITE 300
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1711
Practice Address - Country:US
Practice Address - Phone:262-363-1717
Practice Address - Fax:262-363-1726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY VISION & CONTACT LENS CTRS SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0345670004Medicare NSC