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General NPI Number Information
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NPI Number | 1376718536
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Entity Type | Organization
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Legal Business Name | FAMILY VISION & CONTACT LENS CTRS SC
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Dates
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Enumeration Date | 04/28/2008
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Last Update Date | 04/09/2012
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Provider Practice Location Address
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Address Line | 920 GREENWALD CT SUITE 300
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City | MUKWONAGO
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State | WI
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Zip | 53149-1711
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Country | US
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Telephone | 262-363-1717
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Fax | 262-363-1726
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Provider Business Mailing Address
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Address Line | PO BOX 630 309 MCHENRY ST
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City | BURLINGTON
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State | WI
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Zip | 53105
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Country | US
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Telephone | 262-763-0117
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Fax | 262-763-0119
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT LAWRENCE FAIT
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Credential | OD
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Telephone | 262-763-0117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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