Healthcare Provider Details

I. General information

NPI: 1831364090
Provider Name (Legal Business Name): FAMILY VISION & CONTACT LENS CTRS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E MAIN ST
TWIN LAKES WI
53181-9682
US

IV. Provider business mailing address

PO BOX 630
BURLINGTON WI
53105-0630
US

V. Phone/Fax

Practice location:
  • Phone: 262-877-3999
  • Fax: 262-877-9862
Mailing address:
  • Phone: 262-763-0117
  • Fax: 262-763-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT LAWRENCE FAIT
Title or Position: OWNER
Credential: OD
Phone: 262-763-0117