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General NPI Number Information
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NPI Number | 1679520845
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Entity Type | Organization
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Legal Business Name | SUMMIT EYE CLINIC SC
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Dates
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Enumeration Date | 05/31/2006
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Last Update Date | 03/11/2011
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Provider Practice Location Address
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Address Line | 608 EAST SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3841
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Country | US
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Telephone | 262-567-6565
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Fax | 262-567-8214
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Provider Business Mailing Address
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Address Line | 608 E SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066
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Country | US
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Telephone | 262-567-6565
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Fax | 262-567-8214
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Authorized Official
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Title or Position | PRESIDENT
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Name | RANDY J PRESTASH
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Credential | OD
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Telephone | 262-567-6565
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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 | 1780
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License Number State | WI
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