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General NPI Number Information
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NPI Number | 1275799629
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Entity Type | Organization
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Legal Business Name | MAYVILLE VISION CENTER, INC.
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Dates
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Enumeration Date | 08/05/2008
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Last Update Date | 06/17/2009
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Provider Practice Location Address
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Address Line | 935 HORICON ST
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City | MAYVILLE
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State | WI
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Zip | 53050-1428
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Country | US
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Telephone | 920-387-3180
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Fax | 920-387-9636
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Provider Business Mailing Address
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Address Line | 935 HORICON ST
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City | MAYVILLE
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State | WI
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Zip | 53050-1428
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Country | US
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Telephone | 920-387-3180
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Fax | 920-387-9636
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Authorized Official
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Title or Position | OPTOMETRIST/PRESIDENT
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Name | DR. CASSANDRE BEZOLD HETZER
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Credential | O.D.
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Telephone | 920-387-3180
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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 | WI 2915-035
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License Number State | WI
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