=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619604972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYCE BOENTE OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2022
-----------------------------------------------------
Last Update Date | 08/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1166 W SUNSET DR
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53189-8441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-574-9410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1632 N FRANKLIN PL APT 411
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-710-2933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3804-35
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------