Provider Demographics
NPI:1316152499
Name:EYEWEAR UNLIMITED INCORPORATED
Entity type:Organization
Organization Name:EYEWEAR UNLIMITED INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMEBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-261-6290
Mailing Address - Street 1:615 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3874
Mailing Address - Country:US
Mailing Address - Phone:920-261-6290
Mailing Address - Fax:920-261-6597
Practice Address - Street 1:615 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3874
Practice Address - Country:US
Practice Address - Phone:920-261-6290
Practice Address - Fax:920-261-6597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047765Medicare UPIN