Healthcare Provider Details

I. General information

NPI: 1528143500
Provider Name (Legal Business Name): SE PROFESSIONALS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MARTIN DR
FREDONIA WI
53021-9455
US

IV. Provider business mailing address

120 MARTIN DR
FREDONIA WI
53021-9455
US

V. Phone/Fax

Practice location:
  • Phone: 262-692-9000
  • Fax: 262-692-2797
Mailing address:
  • Phone: 262-692-9000
  • Fax: 262-692-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAVID KING AYMOND
Title or Position: OWNER
Credential: MD
Phone: 920-467-7000