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General NPI Number Information
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NPI Number | 1497071211
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Entity Type | Organization
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Legal Business Name | RGM EYECARE, LLC
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Dates
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Enumeration Date | 04/19/2010
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Last Update Date | 05/03/2010
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Provider Practice Location Address
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Address Line | 4304 TAYLOR AVE
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City | RACINE
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State | WI
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Zip | 53405-4641
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Country | US
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Telephone | 262-404-5001
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Fax |
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Provider Business Mailing Address
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Address Line | 4304 TAYLOR AVE
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City | RACINE
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State | WI
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Zip | 53405-4641
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Country | US
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Telephone | 262-404-5001
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST/ MANAGING MEMBER
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Name | DR. ROBERT G MAHONEY
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Credential | O.D.
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Telephone | 12624045001
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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 | 2190-035
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License Number State | WI
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