Provider Demographics
NPI:1447344593
Name:WOLF RIVER EYECARE LLC
Entity type:Organization
Organization Name:WOLF RIVER EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-982-4561
Mailing Address - Street 1:1923 N SHAWANO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-7510
Mailing Address - Country:US
Mailing Address - Phone:920-982-4561
Mailing Address - Fax:920-982-9811
Practice Address - Street 1:1923 N SHAWANO ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-7510
Practice Address - Country:US
Practice Address - Phone:920-982-4561
Practice Address - Fax:920-982-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2483-035152W00000X
WI2752-035152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38719600Medicaid
WIWI1370Medicare PIN
WI6298870001Medicare NSC