Provider Demographics
NPI:1952595480
Name:KIVLIN EYE CLINIC, SC
Entity Type:Organization
Organization Name:KIVLIN EYE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:KIVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-263-2600
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:370 3RD AVE
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005
Mailing Address - Country:US
Mailing Address - Phone:715-263-2600
Mailing Address - Fax:715-263-3233
Practice Address - Street 1:370 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005
Practice Address - Country:US
Practice Address - Phone:715-263-2600
Practice Address - Fax:715-263-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1539-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38702400Medicaid
WI0523040002OtherDMERC
WI38702400Medicaid
WI0523040002OtherDMERC
WI0523040002Medicare NSC