=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861590200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANDON VISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 E WASHINGTON ST
-----------------------------------------------------
City | CRANDON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54520-1392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-478-2401
-----------------------------------------------------
Fax | 715-478-3663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 E WASHINGTON ST
-----------------------------------------------------
City | CRANDON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54520-1392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-478-2401
-----------------------------------------------------
Fax | 715-478-3663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JEAN ANN WHITT-BARKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-478-2401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1494-035
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------