Basic Information
| Provider Information | |||||||||
| NPI: | 1568445062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE SURGERY & LASER CENTER OF WISCONSIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10200 W INNOVATION DRIVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143029196 | ||||||||
| FaxNumber: | 4147734668 | ||||||||
| Practice Location | |||||||||
| Address1: | 10200 W INNOVATION DR | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143029196 | ||||||||
| FaxNumber: | 4147734666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GUNNELSON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4147734662 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN, CASC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 41910800 | 05 | WI | MEDICAID |