Provider Demographics
NPI:1578640223
Name:ADVANCED FAMILY EYECARE
Entity Type:Organization
Organization Name:ADVANCED FAMILY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-258-8168
Mailing Address - Street 1:308 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1422
Mailing Address - Country:US
Mailing Address - Phone:715-258-8168
Mailing Address - Fax:715-258-8436
Practice Address - Street 1:308 W FULTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1422
Practice Address - Country:US
Practice Address - Phone:715-258-8168
Practice Address - Fax:715-258-8436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38716100Medicaid
WI38716100Medicaid
WI0187380001Medicare NSC