Provider Demographics
NPI:1790173425
Name:THIELKE FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:THIELKE FAMILY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:N
Authorized Official - Last Name:THIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-808-0480
Mailing Address - Street 1:911 WERT RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2212 GLACIER DR
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-8347
Practice Address - Country:US
Practice Address - Phone:715-483-2571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3145-035152W00000X
MN3183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1616Medicare UPIN