Provider Demographics
NPI:1659492254
Name:RACINE OPTICAL CO., FAMILY VISION CARE, INC
Entity Type:Organization
Organization Name:RACINE OPTICAL CO., FAMILY VISION CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-634-4430
Mailing Address - Street 1:217 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1213
Mailing Address - Country:US
Mailing Address - Phone:262-634-4430
Mailing Address - Fax:262-634-1890
Practice Address - Street 1:217 6TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1213
Practice Address - Country:US
Practice Address - Phone:262-634-4430
Practice Address - Fax:262-634-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2220251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38574400Medicaid
WI000047405OtherMEDICARE GROUP NUMBER
WIDG4459OtherRAILROAD MEDICARE PART B
WI000047405OtherMEDICARE GROUP NUMBER
WI000047373Medicare PIN