Provider Demographics
NPI:1649740713
Name:WISCONSIN PHYSICIANS EYECARE GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN PHYSICIANS EYECARE GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-208-8464
Mailing Address - Street 1:1615 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-6300
Mailing Address - Country:US
Mailing Address - Phone:561-275-2020
Mailing Address - Fax:
Practice Address - Street 1:4302 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3722
Practice Address - Country:US
Practice Address - Phone:608-241-1600
Practice Address - Fax:608-241-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty