Provider Demographics
NPI:1710905781
Name:EYE CENTERS OF RACINE AND KENOSHA LTD
Entity Type:Organization
Organization Name:EYE CENTERS OF RACINE AND KENOSHA LTD
Other - Org Name:EYE CENTER OF RACINE LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-637-8835
Mailing Address - Street 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-637-0500
Mailing Address - Fax:262-635-8027
Practice Address - Street 1:3805B SPRING ST STE 140
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1642
Practice Address - Country:US
Practice Address - Phone:262-637-8835
Practice Address - Fax:262-635-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38713800Medicaid
WI0631860001OtherNGS ADMINISTAR
WI100202317Medicaid
WI0631860001OtherNGS ADMINISTAR
WI38713800Medicaid