Provider Demographics
NPI:1750945028
Name:EYEGLASS SHOPP LLC
Entity type:Organization
Organization Name:EYEGLASS SHOPP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BAILEN
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:715-682-8181
Mailing Address - Street 1:200 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-1606
Mailing Address - Country:US
Mailing Address - Phone:715-682-8181
Mailing Address - Fax:715-682-8181
Practice Address - Street 1:200 MAIN ST W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1606
Practice Address - Country:US
Practice Address - Phone:715-682-8181
Practice Address - Fax:715-682-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100085010Medicaid