MEDICARE: OREGON FAMILY EYE 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	2924	WI

General Provider Information

NPI Number	:	1891826566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON FAMILY EYE CARE, LLC

Provider Business Mailing Address
First Line	:	600 PLEASANT OAK DR
Second Line	:	SUITE D
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:	608-835-6658
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 PLEASANT OAK DR
Second Line	:	SUITE D
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:	608-835-6658
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF OPTOMETRY
Name	:	DR. KRISTOPHER LEE GLANVILLE
Credential	:	O.D.
Telephone Number	:	608-835-6658

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	08/22/2020

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