Provider Demographics
NPI:1336216472
Name:KIVLIN EYE CLINIC SC
Entity type:Organization
Organization Name:KIVLIN EYE CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KIVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-235-3838
Mailing Address - Street 1:2303 SCHNEIDER AVE SE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7005
Mailing Address - Country:US
Mailing Address - Phone:715-235-3838
Mailing Address - Fax:715-235-3846
Practice Address - Street 1:2303 SCHNEIDER AVE SE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7005
Practice Address - Country:US
Practice Address - Phone:715-235-3838
Practice Address - Fax:715-235-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1539035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0523040001OtherDMERC
WI38564800Medicaid
WI0523040001OtherDMERC
WI0523040001Medicare NSC
WIT62422Medicare UPIN