=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467558536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KNIGHT VISION & GLAUCOMA SPECIALISTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2006
-----------------------------------------------------
Last Update Date | 03/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 W GREENFIELD AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-4729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-453-6667
-----------------------------------------------------
Fax | 414-774-5505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 W GREENFIELD AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-4729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-453-6667
-----------------------------------------------------
Fax | 414-774-5505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DAWN M. BOULANGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-453-2534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2138-035
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------