Basic Information
| Provider Information | |||||||||
| NPI: | 1407801087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEG WISCONSIN PROFESSIONAL LTD | ||||||||
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| OtherOrganizationName: | CHRISTENSON VISION CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 E 4TH ST STE 440 | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153811234 | ||||||||
| FaxNumber: | 7153815357 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 VINE ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540165802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153811234 | ||||||||
| FaxNumber: | 7153815357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR RCM/MVC | ||||||||
| AuthorizedOfficialTelephone: | 6186045208 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 1992-035 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Pediatrics |
No ID Information.