Provider Demographics
NPI:1972778140
Name:FAMILY VISION & CONTACT LENS CTRS SC
Entity type:Organization
Organization Name:FAMILY VISION & CONTACT LENS CTRS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:FAIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-763-0117
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:309 MCHENRY ST
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105
Mailing Address - Country:US
Mailing Address - Phone:262-763-0117
Mailing Address - Fax:262-763-0119
Practice Address - Street 1:8469 S HOWELL AVE
Practice Address - Street 2:#2
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154
Practice Address - Country:US
Practice Address - Phone:414-768-0110
Practice Address - Fax:414-768-0116
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY VISION & CONTACT LENS CTRS SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0345670005Medicare NSC