=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336285998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARLE VISION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 S 76TH ST
-----------------------------------------------------
City | GREENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53129-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-421-9330
-----------------------------------------------------
Fax | 414-421-3159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 S 76TH ST SOUTHRIDGE MALL #1350
-----------------------------------------------------
City | GREENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53129-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-421-9330
-----------------------------------------------------
Fax | 414-421-3159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICARE SUPERVISOR
-----------------------------------------------------
Name | WENDY UHLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-765-3534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------