Provider Demographics
NPI:1063616571
Name:SIREN FAMILY EYECARE, LLC
Entity type:Organization
Organization Name:SIREN FAMILY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-349-2733
Mailing Address - Street 1:P.O. BOX 290
Mailing Address - Street 2:24082 STATE ROAD 35
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0290
Mailing Address - Country:US
Mailing Address - Phone:715-349-2733
Mailing Address - Fax:715-349-2744
Practice Address - Street 1:24082 STATE ROAD 35
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872
Practice Address - Country:US
Practice Address - Phone:715-349-2733
Practice Address - Fax:715-349-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38725900OtherGROUP HEALTH OF EAU CLAIRE
WI21-00884OtherMEDICA EYEWEAR PIN
WI38725900Medicaid
WI47955OtherSPECTERA/OPTUM HEALTH
WI57568OtherDAVIS VISION
WI57568OtherDAVIS VISION
WI38725900Medicaid