Provider Demographics
NPI:1215110424
Name:ERICKSON EYE CARE, P.C.
Entity type:Organization
Organization Name:ERICKSON EYE CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:ERICKSON
Authorized Official - Last Name:GARBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-799-4138
Mailing Address - Street 1:N4637 TIMBERCREST DR E
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8623
Mailing Address - Country:US
Mailing Address - Phone:608-799-4138
Mailing Address - Fax:608-781-1590
Practice Address - Street 1:2656 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:FORT MCCOY
Practice Address - State:WI
Practice Address - Zip Code:54656-5240
Practice Address - Country:US
Practice Address - Phone:608-388-5997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3129-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508962879OtherINDIVIDUAL NPI
IAI17029OtherMEDICARE INDIVIDUAL PIN
IAI17050OtherMEDICARE GROUP PIN
IAI17050OtherMEDICARE GROUP PIN
IA1508962879OtherINDIVIDUAL NPI