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General NPI Number Information
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NPI Number | 1669004149
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Entity Type | Organization
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Legal Business Name | MYEYEDR OPTOMETRY OF WISCONSIN, LLC
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Dates
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Enumeration Date | 02/12/2020
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 217 6TH ST
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City | RACINE
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State | WI
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Zip | 53403-1213
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Country | US
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Telephone | 262-634-4430
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Fax | 262-634-1890
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Provider Business Mailing Address
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Address Line | 1950 OLD GALLOWS RD STE 520
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City | VIENNA
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State | VA
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Zip | 22182-3970
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Country | US
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Telephone | 703-847-8899
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Fax | 571-223-6780
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Authorized Official
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Title or Position | SECRETARY
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Name | SUE DOWNES
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Credential |
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Telephone | 703-847-8899
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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 |
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License Number State |
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