Healthcare Provider Details

I. General information

NPI: 1194736892
Provider Name (Legal Business Name): CENTER OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 N CENTRAL AVE
RICHLAND CENTER WI
53581-2225
US

IV. Provider business mailing address

132 N CENTRAL AVE
RICHLAND CENTER WI
53581-2225
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-7369
  • Fax: 608-647-2292
Mailing address:
  • Phone: 608-647-7369
  • Fax: 608-647-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMD88588
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number03945
License Number StateWI

VIII. Authorized Official

Name: MRS. JUDY ANN HEIN
Title or Position: VICE PRESIDENT/CFO
Credential:
Phone: 608-647-7369