Healthcare Provider Details

I. General information

NPI: 1114935095
Provider Name (Legal Business Name): WILLIAM R PIERRE OD TPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/10/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 MISHKOSEN DR FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
CRANDON WI
54520
US

IV. Provider business mailing address

PO BOX 396
CRANDON WI
54520-0396
US

V. Phone/Fax

Practice location:
  • Phone: 715-478-4300
  • Fax: 715-478-4490
Mailing address:
  • Phone: 715-478-4300
  • Fax: 715-478-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1897035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: