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General NPI Number Information
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NPI Number | 1972871572
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Entity Type | Organization
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Legal Business Name | BADGER VISION CENTER, LLC
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 2505 N MAYFAIR RD STE 100
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City | WAUWATOSA
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State | WI
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Zip | 53226-1404
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Country | US
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Telephone | 414-453-7020
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Fax | 414-453-9980
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Provider Business Mailing Address
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Address Line | 2505 N MAYFAIR RD STE 100
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City | WAUWATOSA
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State | WI
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Zip | 53226-1404
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Country | US
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Telephone | 414-453-7020
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Fax | 414-453-9980
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Authorized Official
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Title or Position | DISREGARDED ENTITY
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Name | DR. JOEL D BAISDEN
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Credential | OD
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Telephone | 414-453-7020
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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 | 2283
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License Number State | WI
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