Healthcare Provider Details

I. General information

NPI: 1215078258
Provider Name (Legal Business Name): KOLAR OPTOMETRIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 MARKET ST
NEKOOSA WI
54457-1126
US

IV. Provider business mailing address

404 MARKET ST PO BOX 187
NEKOOSA WI
54457-1126
US

V. Phone/Fax

Practice location:
  • Phone: 715-886-4731
  • Fax: 715-886-4706
Mailing address:
  • Phone: 715-886-4731
  • Fax: 715-886-4706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER MICHAEL KOLAR
Title or Position: MANAGING MEMBER
Credential: O.D.
Phone: 715-886-4731