Provider Demographics
NPI:1053769547
Name:HAYWARD FAMILY EYE CARE, INC
Entity type:Organization
Organization Name:HAYWARD FAMILY EYE CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERIKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-271-9899
Mailing Address - Street 1:1200 PARK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-5316
Mailing Address - Country:US
Mailing Address - Phone:715-271-9899
Mailing Address - Fax:
Practice Address - Street 1:15569 RAILROAD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5706
Practice Address - Country:US
Practice Address - Phone:715-634-8616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2235-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38577900Medicaid
WI410040194Medicare PIN
WI38577900Medicaid
U20693Medicare UPIN