Provider Demographics
NPI:1992773998
Name:SPOONER EYE CARE SC
Entity type:Organization
Organization Name:SPOONER EYE CARE SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SHELLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-520-3606
Mailing Address - Street 1:1611 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2073
Mailing Address - Country:US
Mailing Address - Phone:715-520-3414
Mailing Address - Fax:
Practice Address - Street 1:1611 RIVER ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2073
Practice Address - Country:US
Practice Address - Phone:715-520-3414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2200142OtherMEDICA
WI38723400Medicaid
=========013OtherBLUE CROSS BLUE SHIELD
WI38723400Medicaid