Healthcare Provider Details

I. General information

NPI: 1851577829
Provider Name (Legal Business Name): EYE CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2008
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7363 STATE ROAD 50
LAKE GENEVA WI
53147-4516
US

IV. Provider business mailing address

7363 STATE ROAD 50
LAKE GENEVA WI
53147-4516
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-8577
  • Fax: 262-248-8757
Mailing address:
  • Phone: 262-248-8577
  • Fax: 262-248-8757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number18321
License Number StateWI

VIII. Authorized Official

Name: NICHOLAS WILLIM VEITH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-248-8577