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General NPI Number Information
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NPI Number | 1376724377
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Entity Type | Organization
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Legal Business Name | OCONOMOWOC VISION CLINIC, LLC
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Dates
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Enumeration Date | 11/18/2007
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Last Update Date | 05/10/2013
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Provider Practice Location Address
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Address Line | 1674 OLD SCHOOLHOUSE RD SUITE 101
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City | OCONOMOWOC
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State | WI
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Zip | 53066-1396
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Country | US
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Telephone | 262-567-2295
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Fax | 262-567-0744
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Provider Business Mailing Address
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Address Line | 1674 OLD SCHOOLHOUSE RD SUITE 101
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City | OCONOMOWOC
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State | WI
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Zip | 53066-1396
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Country | US
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Telephone | 262-567-2295
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Fax | 262-567-0744
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | DAVID MARK BJORK
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Credential | O.D.
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Telephone | 262-567-2295
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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 | 3017
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License Number State | WI
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