Provider Demographics
NPI:1154694677
Name:DOWNTOWN OPTICAL LLC
Entity type:Organization
Organization Name:DOWNTOWN OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:KRETZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-298-3308
Mailing Address - Street 1:330 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5545
Mailing Address - Country:US
Mailing Address - Phone:715-298-3308
Mailing Address - Fax:715-298-2445
Practice Address - Street 1:330 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5545
Practice Address - Country:US
Practice Address - Phone:715-298-3308
Practice Address - Fax:715-298-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447532940Medicaid