Provider Demographics
NPI:1194922690
Name:MENOMONIE EYE & OPTICAL LLC
Entity type:Organization
Organization Name:MENOMONIE EYE & OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOMRO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-235-2855
Mailing Address - Street 1:520 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2516
Mailing Address - Country:US
Mailing Address - Phone:715-235-2855
Mailing Address - Fax:715-235-9436
Practice Address - Street 1:520 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2516
Practice Address - Country:US
Practice Address - Phone:715-235-2855
Practice Address - Fax:715-235-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38721600Medicaid
WI38721600Medicaid