=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417679754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZPEXXTU SPECS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 09/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N92W17420 APPLETON AVE STE 103-159
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-1363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-330-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 W BROWN DEER RD # 254
-----------------------------------------------------
City | BROWN DEER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-330-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. NICOLE STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-330-0410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------