Provider Demographics
NPI:1538296363
Name:VALLEY VIEW VISION SC
Entity Type:Organization
Organization Name:VALLEY VIEW VISION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-646-1336
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:CENTURIA
Mailing Address - State:WI
Mailing Address - Zip Code:54824-0400
Mailing Address - Country:US
Mailing Address - Phone:715-646-1336
Mailing Address - Fax:
Practice Address - Street 1:416 SUPERIOR AVENUE
Practice Address - Street 2:
Practice Address - City:CENTURIA
Practice Address - State:WI
Practice Address - Zip Code:54824
Practice Address - Country:US
Practice Address - Phone:715-646-1336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty