Provider Demographics
NPI:1487710539
Name:I C 20 20 EAU CLAIRE INC
Entity type:Organization
Organization Name:I C 20 20 EAU CLAIRE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-833-1220
Mailing Address - Street 1:4054 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-9000
Mailing Address - Country:US
Mailing Address - Phone:715-833-1220
Mailing Address - Fax:715-833-1297
Practice Address - Street 1:4054 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-9000
Practice Address - Country:US
Practice Address - Phone:715-833-1220
Practice Address - Fax:715-833-1297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-30
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2275035332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38711700Medicaid
WI38711700Medicaid
WI4465390001Medicare NSC
WI000087289Medicare PIN