Healthcare Provider Details

I. General information

NPI: 1740317841
Provider Name (Legal Business Name): ALEXANDER EYE INSTITUTE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N METRO DRIVE
APPLETON WI
54913-8571
US

IV. Provider business mailing address

250 N METRO DRIVE
APPLETON WI
54913-8571
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-2020
  • Fax: 920-830-1118
Mailing address:
  • Phone: 920-830-2020
  • Fax: 920-830-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number30180
License Number StateWI

VIII. Authorized Official

Name: MRS. KIMBERLY KAY GODDARD
Title or Position: OPHTHALMIC TECHNICIAN
Credential: COT/ROOB
Phone: 920-830-2020