Healthcare Provider Details

I. General information

NPI: 1497034078
Provider Name (Legal Business Name): ALLIED FAMILY EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 ARCADIAN AVE
WAUKESHA WI
53186-5391
US

IV. Provider business mailing address

PO BOX 992
WAUKESHA WI
53187-0992
US

V. Phone/Fax

Practice location:
  • Phone: 414-559-8915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number2653
License Number StateWI

VIII. Authorized Official

Name: TRACY BUEGE
Title or Position: MANAGER
Credential:
Phone: 414-559-8915