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General NPI Number Information
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NPI Number | 1114150828
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Entity Type | Organization
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Legal Business Name | ESSENTIAL EYECARE, LLC
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/27/2009
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Provider Practice Location Address
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Address Line | 250 RICHMOND WAY
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City | NEW RICHMOND
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State | WI
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Zip | 54017-6829
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Country | US
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Telephone | 715-246-2894
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Fax | 715-246-2894
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Provider Business Mailing Address
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Address Line | 250 RICHMOND WAY
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City | NEW RICHMOND
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State | WI
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Zip | 54017-6829
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Country | US
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Telephone | 715-246-2894
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Fax | 715-246-2894
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ANGELA PORCH JOHNSON
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Credential | O.D.
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Telephone | 651-270-1621
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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 | 3023-035
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License Number State | WI
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