Healthcare Provider Details

I. General information

NPI: 1861463234
Provider Name (Legal Business Name): COMMUNITY EYECARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 APPLETON RD
MENASHA WI
54952-1501
US

IV. Provider business mailing address

1255 APPLETON RD
MENASHA WI
54952-1501
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2676
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2869
License Number StateWI

VIII. Authorized Official

Name: MRS. GWEN E SCHREIBER
Title or Position: OFFICE MANAGER
Credential:
Phone: 920-722-6872