Provider Demographics
NPI:1699789032
Name:VALLEY EYE ASSOCIATES
Entity type:Organization
Organization Name:VALLEY EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-749-4058
Mailing Address - Street 1:21 PARK PL
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8872
Mailing Address - Country:US
Mailing Address - Phone:920-739-4361
Mailing Address - Fax:920-739-6368
Practice Address - Street 1:21 PARK PL
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8872
Practice Address - Country:US
Practice Address - Phone:920-739-4361
Practice Address - Fax:920-739-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32681900Medicaid
WI32681900Medicaid