=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275783318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WADE FAMILY EYE CARE, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2008
-----------------------------------------------------
Last Update Date | 03/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2044 15TH AVE.
-----------------------------------------------------
City | CAMERON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54822-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-458-3937
-----------------------------------------------------
Fax | 715-458-3938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2044 15TH AVE.
-----------------------------------------------------
City | CAMERON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54822-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-458-3937
-----------------------------------------------------
Fax | 715-458-3938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. GEORGEANN STEVERMER WADE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 715-458-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2643
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------