Provider Demographics
NPI:1477522324
Name:VALLEY VISION CLINIC SC
Entity Type:Organization
Organization Name:VALLEY VISION CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-725-1566
Mailing Address - Street 1:1513 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4801
Mailing Address - Country:US
Mailing Address - Phone:920-725-1566
Mailing Address - Fax:920-725-8810
Practice Address - Street 1:1513 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4801
Practice Address - Country:US
Practice Address - Phone:920-725-1566
Practice Address - Fax:920-725-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0754900001Medicare NSC