Provider Demographics
NPI:1609091313
Name:KOSKINEN EYE CLINIC, LLC
Entity Type:Organization
Organization Name:KOSKINEN EYE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLENA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-642-9719
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-0165
Mailing Address - Country:US
Mailing Address - Phone:262-642-9719
Mailing Address - Fax:262-642-2228
Practice Address - Street 1:3278 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120
Practice Address - Country:US
Practice Address - Phone:262-642-9719
Practice Address - Fax:262-642-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047396Medicare PIN
WI5519390001Medicare NSC