Provider Demographics
NPI:1699969410
Name:CARDINAL FAMILY EYE CARE LLC
Entity type:Organization
Organization Name:CARDINAL FAMILY EYE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:VERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-861-5253
Mailing Address - Street 1:331 E PRAIRIE VIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-3463
Mailing Address - Country:US
Mailing Address - Phone:715-726-9077
Mailing Address - Fax:715-726-9173
Practice Address - Street 1:331 E PRAIRIE VIEW RD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3463
Practice Address - Country:US
Practice Address - Phone:715-726-9077
Practice Address - Fax:715-726-9173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDINAL FAMILY EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3081-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38726600Medicaid
WI38726600Medicaid
WI000047999Medicare PIN