Basic Information
| Provider Information | |||||||||
| NPI: | 1538422027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | JANICE | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11340 N PT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622400455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11340 N. PT. WASHINGTON RD. | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622400455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3269-35 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 020677066 | 01 | WI | EMPLOYER/STORE | OTHER |