Basic Information
| Provider Information | |||||||||
| NPI: | 1407589740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEG WISCONSIN VISION THERAPY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 E 4TH ST STE 440 | ||||||||
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| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 VINE ST STE C | ||||||||
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| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540165862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153811577 | ||||||||
| FaxNumber: | 7153815357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2022 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR RCM/MVC | ||||||||
| AuthorizedOfficialTelephone: | 6184629818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WV0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Vision Therapy |
No ID Information.