Healthcare Provider Details

I. General information

NPI: 1992773998
Provider Name (Legal Business Name): SPOONER EYE CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 RIVER ST
PAYETTE ID
83661-2073
US

IV. Provider business mailing address

1611 RIVER ST
PAYETTE ID
83661-2073
US

V. Phone/Fax

Practice location:
  • Phone: 715-520-3414
  • Fax:
Mailing address:
  • Phone: 715-520-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SONDRA KAY SHELLITO
Title or Position: OFFICE MANAGER
Credential:
Phone: 715-520-3606