Provider Demographics
NPI:1205953866
Name:ESSENTIAL FAMILY VISION CARE, S.C.
Entity type:Organization
Organization Name:ESSENTIAL FAMILY VISION CARE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-846-5625
Mailing Address - Street 1:101 S. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DE FOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-5625
Mailing Address - Fax:608-846-8998
Practice Address - Street 1:101 S. MAIN ST
Practice Address - Street 2:
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:608-846-5625
Practice Address - Fax:608-846-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38723200Medicaid
WI000247800Medicare ID - Type UnspecifiedDR JULIA EDWARDS
WI38723200Medicaid
WIT16837Medicare UPIN
WI5398900001Medicare NSC
WI000147800Medicare ID - Type UnspecifiedDR TRIXIE EAKIN