Healthcare Provider Details

I. General information

NPI: 1164992996
Provider Name (Legal Business Name): MYEYEDR OPTOMETRY OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 30TH AVE
KENOSHA WI
53144-1411
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 262-597-2020
  • Fax: 262-597-5452
Mailing address:
  • Phone: 703-847-8899
  • Fax: 866-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUE HEALEY
Title or Position: CEO
Credential:
Phone: 703-847-8899