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General NPI Number Information
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NPI Number | 1780848523
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Entity Type | Organization
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Legal Business Name | ADVANCED EYECARE & CONTACT LENS CENTER, LLC
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Dates
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Enumeration Date | 07/10/2008
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Last Update Date | 07/15/2008
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Provider Practice Location Address
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Address Line | 154 E GENEVA SQ
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City | LAKE GENEVA
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State | WI
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Zip | 53147-9694
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Country | US
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Telephone | 262-249-1000
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Fax | 262-249-1255
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Provider Business Mailing Address
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Address Line | 154 E GENEVA SQ
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City | LAKE GENEVA
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State | WI
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Zip | 53147-9694
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Country | US
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Telephone | 262-249-1000
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Fax | 262-249-1255
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Authorized Official
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Title or Position | OWNER
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Name | DR. INGER GIBSON
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Credential | OD
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Telephone | 262-249-1000
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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 | 2495
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License Number State | WI
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