Healthcare Provider Details

I. General information

NPI: 1326143157
Provider Name (Legal Business Name): JANET S WHITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E MAIN ST
WAUPUN WI
53963-0163
US

IV. Provider business mailing address

PO BOX 163
WAUPUN WI
53963-0163
US

V. Phone/Fax

Practice location:
  • Phone: 920-324-8608
  • Fax: 920-324-8699
Mailing address:
  • Phone: 920-324-8608
  • Fax: 920-324-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANET SUSAN WHITE
Title or Position: OWNER
Credential:
Phone: 920-324-8608