Healthcare Provider Details

I. General information

NPI: 1659833218
Provider Name (Legal Business Name): MYEYEDR OPTOMETRY OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14151 W NATIONAL AVE
NEW BERLIN WI
53151-4528
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 414-541-2100
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUE DOWNES
Title or Position: SECRETARY
Credential:
Phone: 703-847-8899