Provider Demographics
NPI:1669590006
Name:ELLIOTT VISION CENTER INC.
Entity type:Organization
Organization Name:ELLIOTT VISION CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-632-2020
Mailing Address - Street 1:2722 OLD MILL DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1320
Mailing Address - Country:US
Mailing Address - Phone:262-632-2020
Mailing Address - Fax:262-632-7085
Practice Address - Street 1:2722 OLD MILL DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1320
Practice Address - Country:US
Practice Address - Phone:262-632-2020
Practice Address - Fax:262-632-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5128440001Medicare NSC
WI000152602Medicare PIN
WI000052602Medicare PIN