Healthcare Provider Details

I. General information

NPI: 1497071211
Provider Name (Legal Business Name): RGM EYECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 TAYLOR AVE
RACINE WI
53405-4641
US

IV. Provider business mailing address

4304 TAYLOR AVE
RACINE WI
53405-4641
US

V. Phone/Fax

Practice location:
  • Phone: 262-404-5001
  • Fax:
Mailing address:
  • Phone: 262-404-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2190-035
License Number StateWI

VIII. Authorized Official

Name: DR. ROBERT G MAHONEY
Title or Position: OPTOMETRIST/ MANAGING MEMBER
Credential: O.D.
Phone: 12624045001