Provider Demographics
NPI:1083903769
Name:EYE TO EYE OPTICAL
Entity type:Organization
Organization Name:EYE TO EYE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BELLOTTI
Authorized Official - Suffix:II
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:414-491-0397
Mailing Address - Street 1:1659 N SPRING ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1280
Mailing Address - Country:US
Mailing Address - Phone:920-885-3318
Mailing Address - Fax:920-885-3319
Practice Address - Street 1:1659 N SPRING ST STE 101B
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1280
Practice Address - Country:US
Practice Address - Phone:920-885-3318
Practice Address - Fax:920-885-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700951605OtherOLD NPI