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General NPI Number Information
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NPI Number | 1467664680
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Entity Type | Organization
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Legal Business Name | EYE SITE VISION CARE CENTER INC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 10/15/2010
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Provider Practice Location Address
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Address Line | 15425 W NATIONAL AVE
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City | NEW BERLIN
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State | WI
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Zip | 53151-5156
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Country | US
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Telephone | 262-789-6929
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Fax | 262-789-1432
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Provider Business Mailing Address
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Address Line | 15425 W NATIONAL AVE
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City | NEW BERLIN
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State | WI
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Zip | 53151-5156
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Country | US
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Telephone | 262-789-6929
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Fax | 262-789-1432
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Authorized Official
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Title or Position | OWNER
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Name | DR. THOMAS MOTISI
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Credential | OD
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Telephone | 262-786-2020
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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 | 1834
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License Number State | WI
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