Provider Demographics
NPI:1457459836
Name:ANTIGO EYE CARE CENTER
Entity Type:Organization
Organization Name:ANTIGO EYE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BARTLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-623-3620
Mailing Address - Street 1:810 5TH AVE
Mailing Address - Street 2:P O BOX 628
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-1937
Mailing Address - Country:US
Mailing Address - Phone:715-623-3620
Mailing Address - Fax:715-623-3333
Practice Address - Street 1:810 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-1937
Practice Address - Country:US
Practice Address - Phone:715-623-3620
Practice Address - Fax:715-623-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIT61453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38708600-38553700Medicaid
WI410030966Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI0573170001Medicare NSC
WI000087675-0001Medicare ID - Type Unspecified
WI38708600-38553700Medicaid