Provider Demographics
NPI:1629049150
Name:OPTICAL DEPT. OF EYE CLINIC OF RACINE, LTD.
Entity Type:Organization
Organization Name:OPTICAL DEPT. OF EYE CLINIC OF RACINE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAWASKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-637-9615
Mailing Address - Street 1:PO BOX 1677
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53401-1677
Mailing Address - Country:US
Mailing Address - Phone:262-637-9615
Mailing Address - Fax:262-637-4437
Practice Address - Street 1:3805A SPRING ST
Practice Address - Street 2:SUITE 111
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1600
Practice Address - Country:US
Practice Address - Phone:262-637-9615
Practice Address - Fax:262-637-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38436400Medicaid