Healthcare Provider Details

I. General information

NPI: 1568217719
Provider Name (Legal Business Name): MAYVILLE VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 HORICON ST
MAYVILLE WI
53050-1428
US

IV. Provider business mailing address

935 HORICON ST
MAYVILLE WI
53050-1428
US

V. Phone/Fax

Practice location:
  • Phone: 920-387-3180
  • Fax: 920-387-9636
Mailing address:
  • Phone: 920-387-3180
  • Fax: 920-387-9636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHELE LEE LANG
Title or Position: OWNER
Credential: ETC
Phone: 920-387-3180