Provider Demographics
NPI:1508891706
Name:CHIPPEWA VALLEY EYE CLINIC SC
Entity Type:Organization
Organization Name:CHIPPEWA VALLEY EYE CLINIC SC
Other - Org Name:CHIPPEWA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V PRES
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-723-6520
Mailing Address - Street 1:2525 CTH I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729
Mailing Address - Country:US
Mailing Address - Phone:715-723-6520
Mailing Address - Fax:715-723-1092
Practice Address - Street 1:2525 CTH I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729
Practice Address - Country:US
Practice Address - Phone:715-723-6520
Practice Address - Fax:715-723-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32846300Medicaid
WI32846300Medicaid