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General NPI Number Information
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NPI Number | 1659492254
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Entity Type | Organization
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Legal Business Name | RACINE OPTICAL CO., FAMILY VISION CARE, INC
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 217 6TH ST
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City | RACINE
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State | WI
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Zip | 53403-1213
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Country | US
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Telephone | 262-634-4430
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Fax | 262-634-1890
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Provider Business Mailing Address
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Address Line | 217 6TH ST
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City | RACINE
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State | WI
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Zip | 53403-1213
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Country | US
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Telephone | 262-634-4430
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Fax | 262-634-1890
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Authorized Official
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Title or Position | CEO
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Name | DR. DEAN ROSENBERG
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Credential | OD
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Telephone | 262-634-4430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number | 2220
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License Number State | WI
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