St Croix Falls Eye Associates
Organization Active NPI Optometrist · Grantsburg, WI
NPI 1174653133 · NPPES record last updated Jun 6, 2023
Key facts
- NPI
- 1174653133
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- 2608-035 (WI)
- Legal business name
- ST CROIX FALLS EYE ASSOCIATES
- Practice address
- 617 S Pine St
Grantsburg, WI 54840-7935 - Phone
- (715) 463-2370
- Fax
- (608) 571-0088
- NPI assigned
- Mar 7, 2007
- Organization subpart
- No
Authorized official
- Name
- Michelle Hall
- Title
- Credentialing
- Phone
- (715) 483-3259
Other NPIs on the same Medicare enrollment 3
Corporate family (same tax ID) 1
Practitioners 3
-
Sandra K Dolphin, O.D.
-
Bruce E Benedict, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040816001181 | WI | Part B Supplier - Clinic/Group Practice | 0244203412 |
Receives reassigned benefits from 3 practitioners 4 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Saint Croix Falls, WI; Webster, WI; Grantsburg, WI; Frederic, WI |
National Provider Directory
- Tax ID family
- St Croix Falls Eye Assoc
Locations
617 S Pine St
Grantsburg, WI 54840
Phone (715) 463-2370
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | 2608-035 | WI | Yes |
| Optometrist |
152W00000X | 2589-035 | WI |
Addresses
Primary practice location
617 S Pine St
Grantsburg, WI 54840-7935
Mailing address
PO Box 767
Saint Croix Falls, WI 54024-0767
Phone (715) 483-3259
Other names
- Grantsburg Eye Associates
Other providers in Grantsburg, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 6, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.