Basic Information
| Provider Information | |||||||||
| NPI: | 1336216472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIVLIN EYE CLINIC SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2303 SCHNEIDER AVE SE | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547517005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152353838 | ||||||||
| FaxNumber: | 7152353846 | ||||||||
| Practice Location | |||||||||
| Address1: | 2303 SCHNEIDER AVE SE | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547517005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152353838 | ||||||||
| FaxNumber: | 7152353846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 02/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIVLIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 7152353838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1539035 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0523040001 | 01 | WI | DMERC | OTHER | 38564800 | 05 | WI | MEDICAID |