Basic Information
| Provider Information | |||||||||
| NPI: | 1528143500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SE PROFESSIONALS, S.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PREMIER VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
| FaxNumber: | 2626922797 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
| FaxNumber: | 2626922797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AYMOND | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | KING | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9204677000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38722100 | 05 | WI | MEDICAID |