Healthcare Provider Details

I. General information

NPI: 1689719437
Provider Name (Legal Business Name): OPHTHALMOLOGY ASSOCIATES S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 S 108TH ST
HALES CORNERS WI
53130-2557
US

IV. Provider business mailing address

6020 S PACKARD AVE
CUDAHY WI
53110-3028
US

V. Phone/Fax

Practice location:
  • Phone: 414-425-9002
  • Fax:
Mailing address:
  • Phone: 414-294-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN GRAVES
Title or Position: OWNER PARTNER
Credential: MD
Phone: 414-294-4660