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General NPI Number Information
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NPI Number | 1255591236
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Entity Type | Organization
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Legal Business Name | DR WAGNER SOUTHRIDGE OPTICAL LLC
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Dates
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Enumeration Date | 06/12/2008
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 5300 S 76TH ST STE 690
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City | GREENDALE
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State | WI
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Zip | 53129-1102
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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 | 5300 S 76TH ST STE 690
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City | GREENDALE
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State | WI
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Zip | 53129-1102
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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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Authorized Official
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Title or Position | MANAGER
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Name | MRS. JOAN E SERRANO
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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 | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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