Healthcare Provider Details

I. General information

NPI: 1710905781
Provider Name (Legal Business Name): EYE CENTERS OF RACINE AND KENOSHA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13200 GLOBE DR STE 216
MT PLEASANT WI
53177-1605
US

IV. Provider business mailing address

3805B SPRING ST SUITE 140
RACINE WI
53405-1641
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-0500
  • Fax: 262-635-8027
Mailing address:
  • Phone: 262-637-0500
  • Fax: 262-635-8027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA GOTTFREDSEN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 262-898-5673