Provider Demographics
NPI:1558426130
Name:FOSTER PRIMARY EYE CARE
Entity Type:Organization
Organization Name:FOSTER PRIMARY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-284-4876
Mailing Address - Street 1:2 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1409
Mailing Address - Country:US
Mailing Address - Phone:715-284-4876
Mailing Address - Fax:715-284-4051
Practice Address - Street 1:2 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1409
Practice Address - Country:US
Practice Address - Phone:715-284-4876
Practice Address - Fax:715-284-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1728-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0693410002Medicare NSC