Provider Demographics
NPI:1942211925
Name:VINCENT R FACCHIANO & ASSOC SC
Entity Type:Organization
Organization Name:VINCENT R FACCHIANO & ASSOC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:R
Authorized Official - Last Name:FACCHIANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-332-2223
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-0427
Mailing Address - Country:US
Mailing Address - Phone:815-332-2223
Mailing Address - Fax:815-332-4488
Practice Address - Street 1:1 W TOWNE MALL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1019
Practice Address - Country:US
Practice Address - Phone:608-829-2440
Practice Address - Fax:608-833-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1865035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI85417Medicare ID - Type Unspecified
WIT38697Medicare UPIN