Healthcare Provider Details

I. General information

NPI: 1952595480
Provider Name (Legal Business Name): KIVLIN EYE CLINIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 3RD AVE
CLEAR LAKE WI
54005
US

IV. Provider business mailing address

PO BOX 15 370 3RD AVE
CLEAR LAKE WI
54005
US

V. Phone/Fax

Practice location:
  • Phone: 715-263-2600
  • Fax: 715-263-3233
Mailing address:
  • Phone: 715-263-2600
  • Fax: 715-263-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1539-035
License Number StateWI

VIII. Authorized Official

Name: DR. JAMES B KIVLIN
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 715-263-2600