Organization
VITA PARK EYE ASSOCIATES, SC
Active
Parent organization
VITA PARK EYE ASSOCIATES, SC
Other names
The Waupun 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
140 GATEWAY DR, WAUPUN, WI 53963-2276
(920) 324-3191
(920) 324-5026
Mailing address
140 GATEWAY DR, WAUPUN, WI 53963-2276
(920) 324-3191
(920) 324-5026
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
207W00000X
Ophthalmology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000016160
OFFICE LOCATION
WI
01
—
0593830001
DEMPOS SUPPLIER NUMBER
—
05
—
21310700
—
WI
01
—
530337
DEANCARE HMO LOCATION
—
01
—
CP765
RAIL ROAD MEDICARE
WI
Enumeration date
07/15/2006
Last updated
04/21/2021
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