Healthcare Provider Details

I. General information

NPI: 1306096417
Provider Name (Legal Business Name): ALTERNATIVE VISION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 COMMONWEALTH DR #4
FORT ATKINSON WI
53538-3147
US

IV. Provider business mailing address

1612 COMMONWEALTH DR #4
FORT ATKINSON WI
53538-3147
US

V. Phone/Fax

Practice location:
  • Phone: 920-397-7094
  • Fax:
Mailing address:
  • Phone: 920-397-7094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2358-035
License Number StateWI

VIII. Authorized Official

Name: DR. MARK F COOK
Title or Position: PROPRIETER
Credential: O.D.
Phone: 920-390-9038