Provider Demographics
NPI:1437253077
Name:RIVER FALLS EYE SURGERY AND LASER CENTER INC.
Entity Type:Organization
Organization Name:RIVER FALLS EYE SURGERY AND LASER CENTER INC.
Other - Org Name:EYE SURGERY AND LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:F
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-425-0115
Mailing Address - Street 1:183 E POMEROY ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3506
Mailing Address - Country:US
Mailing Address - Phone:715-425-0115
Mailing Address - Fax:715-425-6001
Practice Address - Street 1:183 E POMEROY ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3506
Practice Address - Country:US
Practice Address - Phone:715-425-0015
Practice Address - Fax:715-425-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30071-20174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31500600Medicaid
MN375895800Medicaid
WI000056155Medicare PIN
WI31500600Medicaid