=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578865747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OSCEOLA FAMILY EYECARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2010
-----------------------------------------------------
Last Update Date | 01/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 3RD AVE
-----------------------------------------------------
City | OSCEOLA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-294-2500
-----------------------------------------------------
Fax | 715-294-3466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 386
-----------------------------------------------------
City | OSCEOLA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54020-0386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-294-2500
-----------------------------------------------------
Fax | 715-294-3466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIAN D SMITH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 715-294-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | WI2728
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------