Provider Demographics
NPI:1861463234
Name:COMMUNITY EYECARE INC
Entity Type:Organization
Organization Name:COMMUNITY EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCHREIBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-722-6872
Mailing Address - Street 1:1255 APPLETON RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1501
Mailing Address - Country:US
Mailing Address - Phone:920-722-6872
Mailing Address - Fax:920-722-6335
Practice Address - Street 1:1255 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1501
Practice Address - Country:US
Practice Address - Phone:920-722-6872
Practice Address - Fax:920-722-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2869152W00000X
WI2676152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38601700Medicaid
WI0001007160Medicare ID - Type Unspecified
WI1219070001Medicare NSC
WIU86902Medicare UPIN
WI38601700Medicaid
WI000071600Medicare PIN