=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427070259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN J PRUETT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 04/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3805B SPRING ST SUITE 140
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53405-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-637-8835
-----------------------------------------------------
Fax | 262-635-8027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3805B SPRING ST SUITE 140
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53405-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-637-8835
-----------------------------------------------------
Fax | 262-635-8027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1963-035
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------