# VITA PARK EYE ASSOCIATES, SC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** VITA PARK EYE ASSOCIATES, SC
- **Other names:** The Beaver Dam Eye Clinic
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1447276894
- **Legal business name:** VITA PARK EYE ASSOCIATES, SC
- **Authorized official:** THOMAS CASTILLO DO (CORPORATION OFFICER)
- **Authorized official phone:** (920) 887-1151

## Contact information

- **Practice address:** 240 CORPORATE DRIVE, BEAVER DAM, WI 53916-3115
- **Practice address phone:** (920) 887-1151
- **Practice address fax:** (920) 887-3353
- **Mailing address:** 240 CORPORATE DR, BEAVER DAM, WI 53916-3115
- **Mailing address phone:** (920) 887-1151
- **Mailing address fax:** (920) 887-3353

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | — | NULL | — |
| 152W00000X | Optometrist | — | — | — |
| 207W00000X | Ophthalmology Physician | — | NULL | Yes |
| 207W00000X | Ophthalmology Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/15/2006
- **Last updated:** 04/21/2021

## 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 |