Provider Demographics
NPI:1295915460
Name:ANTIGO VISION CLINIC SC
Entity type:Organization
Organization Name:ANTIGO VISION CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:KJOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-623-2180
Mailing Address - Street 1:714 3RD AVE
Mailing Address - Street 2:PO BOX 238
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2044
Mailing Address - Country:US
Mailing Address - Phone:715-623-2180
Mailing Address - Fax:715-623-7244
Practice Address - Street 1:714 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2044
Practice Address - Country:US
Practice Address - Phone:715-623-2180
Practice Address - Fax:715-623-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1477-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38563700Medicaid
WI87410Medicare PIN
WIT62427Medicare UPIN
WI38563700Medicaid