Healthcare Provider Details

I. General information

NPI: 1750519716
Provider Name (Legal Business Name): OCUFOCUS OF JANESVILLE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 LAKE MENDOTA DR
MADISON WI
53705-1248
US

IV. Provider business mailing address

5501 LAKE MENDOTA DR
MADISON WI
53705-1248
US

V. Phone/Fax

Practice location:
  • Phone: 608-239-1218
  • Fax:
Mailing address:
  • Phone: 608-239-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3146-35
License Number StateWI

VIII. Authorized Official

Name: DR. JEREMY MICHAEL GOETSCH
Title or Position: PRESIDENT
Credential: O.D.
Phone: 608-239-1218