Healthcare Provider Details

I. General information

NPI: 1548457757
Provider Name (Legal Business Name): COMMUNITY EYECARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W RYAN ST SUITE A
BRILLION WI
54110
US

IV. Provider business mailing address

1255 APPLETON RD PO BOX 534
MENASHA WI
54952-1501
US

V. Phone/Fax

Practice location:
  • Phone: 920-756-2020
  • Fax: 920-756-2000
Mailing address:
  • Phone: 920-722-6872
  • Fax: 920-722-6335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2869
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2676
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2869
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2676
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2676
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2869
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2676
License Number StateWI
# 8
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2869
License Number StateWI
# 9
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2676
License Number StateWI

VIII. Authorized Official

Name: DR. CHARLES J BURGESS
Title or Position: PRESIDENT
Credential: OD
Phone: 920-722-6872