Healthcare Provider Details

I. General information

NPI: 1083176952
Provider Name (Legal Business Name): MYEYEDR OPTOMETRY OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MARTIN DR
FREDONIA WI
53021-9455
US

IV. Provider business mailing address

1950 OLD GALLOWS RD
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 262-692-9000
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SUE DOWNES
Title or Position: SECRETARY
Credential:
Phone: 703-847-8899