Provider Demographics
NPI:1215078258
Name:KOLAR OPTOMETRIC, LLC
Entity type:Organization
Organization Name:KOLAR OPTOMETRIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOLAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-886-4731
Mailing Address - Street 1:404 MARKET ST
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:NEKOOSA
Mailing Address - State:WI
Mailing Address - Zip Code:54457-1126
Mailing Address - Country:US
Mailing Address - Phone:715-886-4731
Mailing Address - Fax:715-886-4706
Practice Address - Street 1:404 MARKET ST
Practice Address - Street 2:
Practice Address - City:NEKOOSA
Practice Address - State:WI
Practice Address - Zip Code:54457-1126
Practice Address - Country:US
Practice Address - Phone:715-886-4731
Practice Address - Fax:715-886-4706
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOLAR OPTOMETRIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38607400Medicaid
1311030001Medicare NSC
WIU76875Medicare UPIN
WI38607400Medicaid