Healthcare Provider Details

I. General information

NPI: 1063616571
Provider Name (Legal Business Name): SIREN FAMILY EYECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24082 STATE ROAD 35
SIREN WI
54872
US

IV. Provider business mailing address

P.O. BOX 290 24082 STATE ROAD 35
SIREN WI
54872-0290
US

V. Phone/Fax

Practice location:
  • Phone: 715-349-2733
  • Fax: 715-349-2744
Mailing address:
  • Phone: 715-349-2733
  • Fax: 715-349-2744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2728
License Number StateWI

VIII. Authorized Official

Name: DR. BRIAN DARRELL SMITH
Title or Position: MEMBER
Credential: O.D.
Phone: 715-349-2733