Healthcare Provider Details

I. General information

NPI: 1225307242
Provider Name (Legal Business Name): MINOCQUA OPTICAL & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 N. 4TH STREET SUITE 101
TOMAHAWK WI
54487-2137
US

IV. Provider business mailing address

1334 N 4TH ST STE 101
TOMAHAWK WI
54487-2106
US

V. Phone/Fax

Practice location:
  • Phone: 715-224-2200
  • Fax: 419-858-9769
Mailing address:
  • Phone: 715-224-2200
  • Fax: 419-858-9769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGARET ANN COFFEN
Title or Position: OWNER/OPTICIAN
Credential:
Phone: 715-224-2200