Basic Information
| Provider Information | |||||||||
| NPI: | 1285804807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKWOOD EYECARE ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WISCONSIN RAPIDS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544945488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154212111 | ||||||||
| FaxNumber: | 7154212123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WISCONSIN RAPIDS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544945488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154212111 | ||||||||
| FaxNumber: | 7154212123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | STERNITZKY | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | CARL | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7154212111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1687035 | WI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1285804807 | 05 | WI | MEDICAID |