Provider Demographics
NPI:1740443704
Name:EYE CARE SURGICAL CONSULTING SC
Entity type:Organization
Organization Name:EYE CARE SURGICAL CONSULTING SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAPORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-752-2020
Mailing Address - Street 1:4060 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3121
Mailing Address - Country:US
Mailing Address - Phone:262-752-2020
Mailing Address - Fax:
Practice Address - Street 1:4060 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3121
Practice Address - Country:US
Practice Address - Phone:262-752-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2009-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26907-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty