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Organization
VITA PARK EYE ASSOCIATES, SC
Active
Organization
VITA PARK EYE ASSOCIATES, SC
Active
Parent organization
VITA PARK EYE ASSOCIATES, SC
Other names
The Beaver Dam Eye Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
VITA PARK EYE ASSOCIATES, SC
Authorized official
THOMAS CASTILLO DO (CORPORATION OFFICER)
(920) 887-1151
Entity
Organization
Contact information
Practice address
240 CORPORATE DRIVE, BEAVER DAM, WI 53916-3115
(920) 887-1151
(920) 887-3353
Mailing address
240 CORPORATE DR, BEAVER DAM, WI 53916-3115
(920) 887-1151
(920) 887-3353
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
NULL
152W00000X
Optometrist
—
—
207W00000X
Ophthalmology Physician
Primary
—
NULL
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000016160
OFFICE LOCATION
—
01
—
0593830002
DEPMOS SUPPLIER
—
05
—
21310700
—
WI
01
—
519075
DEAN CARE HMO LOCATION
—
01
—
CP765
RAIL ROAD MEDICARE
WI
Enumeration date
07/15/2006
Last updated
04/21/2021
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