Basic Information
| Provider Information | |||||||||
| NPI: | 1164992996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYEYEDR OPTOMETRY OF WISCONSIN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
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| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 30TH AVE | ||||||||
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| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625972020 | ||||||||
| FaxNumber: | 2625975452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2018 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | HEALEY | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7038478899 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.