MEDICARE: OPTOM-EYES CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1063859130	OTHER	WI	NPI TYPE 1

General Provider Information

NPI Number	:	1003484601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOM-EYES CARE LLC

Provider Business Mailing Address
First Line	:	N901 COUNTY HIGHWAY MD
Second Line	:
City	:	SARONA
State	:	WI
Zip	:	54870-9259
Country	:	US
Telephone Number	:	715-651-1944
Fax Number	:	715-934-4759

Provider Business Practice Location Address
First Line	:	15569 RAILROAD ST STE 301
Second Line	:
City	:	HAYWARD
State	:	WI
Zip	:	54843-5707
Country	:	US
Telephone Number	:	715-634-8616
Fax Number	:	715-934-4759

Authorized Official
Title or Position	:	OPTOMETRIST/MANAGER
Name	:	DR. MIKEAL R OSTRANDER
Credential	:	OD
Telephone Number	:	715-651-1944

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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