MEDICARE: WISCONSIN VISION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	65652	OTHER		SPECTERA PROVIDER NO
2	68393	OTHER		DAVIS VISION PROVIDER NO

General Provider Information

NPI Number	:	1023324811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN VISION, LLC

Provider Business Mailing Address
First Line	:	16800 W CLEVELAND AVE
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-3533
Country	:	US
Telephone Number	:	262-432-2005
Fax Number	:	262-432-2006

Provider Business Practice Location Address
First Line	:	5530 N PORT WASHINGTON RD UNIT C
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4920
Country	:	US
Telephone Number	:	262-432-2005
Fax Number	:	262-432-2006

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DARREN THOMAS HORNDASCH
Credential	:
Telephone Number	:	262-432-2005

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	03/02/2026

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