Healthcare Provider Details

I. General information

NPI: 1255983185
Provider Name (Legal Business Name): BEYOND 20-20 VISION THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E BROADWAY AVE
MEDFORD WI
54451-1835
US

IV. Provider business mailing address

309 E BROADWAY AVE
MEDFORD WI
54451-1835
US

V. Phone/Fax

Practice location:
  • Phone: 715-748-2020
  • Fax: 715-748-4565
Mailing address:
  • Phone: 715-748-2020
  • Fax: 715-748-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ELIZABETH KISELICKA
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 715-785-8298