Healthcare Provider Details

I. General information

NPI: 1619015716
Provider Name (Legal Business Name): WISCONSIN VISION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9655 E US HIGHWAY 36 STE E
AVON IN
46123-6212
US

IV. Provider business mailing address

16800 WEST CLEVELAND AVE
NEW BERLIN WI
53151-3533
US

V. Phone/Fax

Practice location:
  • Phone: 317-243-5423
  • Fax: 262-923-7641
Mailing address:
  • Phone: 262-432-2005
  • Fax: 262-432-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. DARREN THOMAS HORNDASCH
Title or Position: PRESIDENT CEO
Credential:
Phone: 262-432-2005