Healthcare Provider Details

I. General information

NPI: 1609839497
Provider Name (Legal Business Name): EYE PROSTHETICS OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13255 W BLUEMOUND RD 101
BROOKFIELD WI
53005-6245
US

IV. Provider business mailing address

13255 W BLUEMOUND RD 101
BROOKFIELD WI
53005-6245
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-3681
  • Fax: 262-754-3682
Mailing address:
  • Phone: 262-754-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN TYNES
Title or Position: OCULARIST
Credential: B.C.O.
Phone: 262-754-3681