MEDICARE: ERICKSON EYE CARE, P.C.

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	3129-035	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	I17029	OTHER	IA	MEDICARE INDIVIDUAL PIN
3	I17050	OTHER	IA	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1508962879	OTHER	IA	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1215110424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERICKSON EYE CARE, P.C.

Provider Business Mailing Address
First Line	:	N4637 TIMBERCREST DR E
Second Line	:
City	:	ONALASKA
State	:	WI
Zip	:	54650-8623
Country	:	US
Telephone Number	:	608-799-4138
Fax Number	:	608-781-1590

Provider Business Practice Location Address
First Line	:	2656 W 12TH AVE
Second Line	:
City	:	FORT MCCOY
State	:	WI
Zip	:	54656-5240
Country	:	US
Telephone Number	:	608-388-5997
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. KENDRA ERICKSON GARBRECHT
Credential	:	O.D.
Telephone Number	:	608-799-4138

Provider Enumeration Date	:	12/11/2007
Last Update Date	:	02/25/2010

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