Healthcare Provider Details

I. General information

NPI: 1083808802
Provider Name (Legal Business Name): CARDINAL FAMILY EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E STANLEY ST
THORP WI
54771-9649
US

IV. Provider business mailing address

102 E STANLEY ST PO BOX 468
THORP WI
54771-9649
US

V. Phone/Fax

Practice location:
  • Phone: 715-669-5631
  • Fax: 715-669-5353
Mailing address:
  • Phone: 715-669-5631
  • Fax: 715-669-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3083-035
License Number StateWI

VIII. Authorized Official

Name: JACOB B VERGIN
Title or Position: MANAGING PARTNER
Credential: OD
Phone: 715-861-5253