=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659645380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYCARE CLINIC, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2012
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N 18TH AVE
-----------------------------------------------------
City | STURGEON BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54235-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-743-9532
-----------------------------------------------------
Fax | 920-743-9538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28900
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54324-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-490-9046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. CHRIS JAY AUGUSTIAN
-----------------------------------------------------
Credential | C.P.A
-----------------------------------------------------
Telephone | 920-405-5382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------