Provider Demographics
NPI:1538142989
Name:TILLMAN OPTOMETRY LLC
Entity Type:Organization
Organization Name:TILLMAN OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-736-1700
Mailing Address - Street 1:2304 S MAIN ST
Mailing Address - Street 2:TILLMAN OPTOMETRY
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-2900
Mailing Address - Country:US
Mailing Address - Phone:715-736-1700
Mailing Address - Fax:
Practice Address - Street 1:2304 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-2900
Practice Address - Country:US
Practice Address - Phone:715-736-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI130004329OtherWEA
WI38563500Medicaid
WI130004329OtherWEA
WI000047261Medicare PIN
WI=========010OtherBCBS