Provider Demographics
NPI:1912023987
Name:COMMUNITY EYECARE CENTER SC
Entity Type:Organization
Organization Name:COMMUNITY EYECARE CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BYERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-258-2020
Mailing Address - Street 1:222 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1531
Mailing Address - Country:US
Mailing Address - Phone:715-258-2020
Mailing Address - Fax:715-258-9301
Practice Address - Street 1:222 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1531
Practice Address - Country:US
Practice Address - Phone:715-258-2020
Practice Address - Fax:715-258-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI110001714OtherWEA
WI38727200Medicaid
WI0541670001Medicare NSC
WI38727200Medicaid
WIU37086Medicare UPIN
WI87943Medicare ID - Type Unspecified
WICC9157Medicare PIN