Provider Demographics
NPI:1396037628
Name:EGGERT & EGGERT LLC
Entity Type:Organization
Organization Name:EGGERT & EGGERT LLC
Other - Org Name:THE EYECARE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:EGGERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-686-1000
Mailing Address - Street 1:700 E MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2256
Mailing Address - Country:US
Mailing Address - Phone:920-686-1000
Mailing Address - Fax:
Practice Address - Street 1:700 E MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2256
Practice Address - Country:US
Practice Address - Phone:920-686-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047354OtherMEDICARE
WI6517120002Medicare NSC