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General NPI Number Information
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NPI Number | 1043859341
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Entity Type | Organization
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Legal Business Name | SITE 4 EYES
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Dates
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Enumeration Date | 01/03/2020
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Last Update Date | 07/08/2020
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Provider Practice Location Address
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Address Line | 7245 S 76TH ST
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City | FRANKLIN
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State | WI
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Zip | 53132-9041
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Country | US
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Telephone | 414-855-0469
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Fax | 414-855-0492
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Provider Business Mailing Address
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Address Line | 7245 S 76TH ST
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City | FRANKLIN
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State | WI
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Zip | 53132-9041
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Country | US
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Telephone | 414-855-0469
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KRISTINA LETICIA WAGNER
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Credential |
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Telephone | 414-855-0469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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