Provider Demographics
NPI:1538357199
Name:EVANSVILLE EYE CLINIC LLC
Entity type:Organization
Organization Name:EVANSVILLE EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LON
Authorized Official - Last Name:SCHOENENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-882-4990
Mailing Address - Street 1:114 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1320
Mailing Address - Country:US
Mailing Address - Phone:608-882-4990
Mailing Address - Fax:608-882-3980
Practice Address - Street 1:114 S MADISON ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1320
Practice Address - Country:US
Practice Address - Phone:608-882-4990
Practice Address - Fax:608-882-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2327332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0245400001Medicare NSC
WI47336Medicare PIN