Provider Demographics
NPI:1972628584
Name:WAUTOMA EYE CLINIC S.C.
Entity Type:Organization
Organization Name:WAUTOMA EYE CLINIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MECKELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-787-3837
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:N2577 PLAZA ROAD
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0366
Mailing Address - Country:US
Mailing Address - Phone:920-787-3837
Mailing Address - Fax:920-787-1613
Practice Address - Street 1:N2577 PLAZA RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7706
Practice Address - Country:US
Practice Address - Phone:920-787-3837
Practice Address - Fax:920-787-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62740Medicare UPIN
WI47186Medicare ID - Type Unspecified