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General NPI Number Information
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NPI Number | 1629494703
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Entity Type | Organization
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Legal Business Name | NORTH SHORE EYE HEALTH AND WELLNESS, SC
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Dates
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Enumeration Date | 03/12/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | N54W6135 MILL ST SUITE 700
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City | CEDARBURG
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State | WI
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Zip | 53012-2021
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Country | US
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Telephone | 262-421-4412
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Fax | 262-421-4413
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Provider Business Mailing Address
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Address Line | N54W6135 MILL ST SUITE 700
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City | CEDARBURG
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State | WI
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Zip | 53012-2021
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Country | US
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Telephone | 262-421-4412
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Fax | 262-421-4413
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KYLE DAVID ROSS
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Credential | OD, FAAO
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Telephone | 262-421-4412
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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 | 3226-035
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License Number State | WI
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