MEDICARE: PENINSULA VISION CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3003	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548445737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA VISION CARE LLC

Provider Business Mailing Address
First Line	:	1426 EGG HARBOR RD
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1240
Country	:	US
Telephone Number	:	920-743-5053
Fax Number	:	920-743-8802

Provider Business Practice Location Address
First Line	:	1426 EGG HARBOR RD
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1240
Country	:	US
Telephone Number	:	920-743-5053
Fax Number	:	920-743-8802

Authorized Official
Title or Position	:	OWNER/ OPTOMETRIST
Name	:	DR. PAUL A FILAR
Credential	:	O.D.
Telephone Number	:	920-743-5053

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	11/25/2024

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