Provider Demographics
NPI:1679990774
Name:KENOSHA FAMILY VISION CARE LLC
Entity Type:Organization
Organization Name:KENOSHA FAMILY VISION CARE LLC
Other - Org Name:REGNER FAMILY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BEGOTKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-694-9103
Mailing Address - Street 1:4014 77TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4314
Mailing Address - Country:US
Mailing Address - Phone:262-694-9103
Mailing Address - Fax:262-694-9106
Practice Address - Street 1:4014 77TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4314
Practice Address - Country:US
Practice Address - Phone:262-694-9103
Practice Address - Fax:262-694-9106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3309-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty