=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871655787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGNER FAMILY VISION CLINIC, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 03/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4014 77TH ST
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-694-9103
-----------------------------------------------------
Fax | 262-694-9106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4014 77TH ST
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-694-9103
-----------------------------------------------------
Fax | 262-694-9106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN L REGNER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 262-694-9103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1356-035
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------