MEDICARE: EYE WISCONSIN 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

General Provider Information

NPI Number	:	1396423273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE WISCONSIN LLC

Provider Business Mailing Address
First Line	:	1090 BUCKS POND RD
Second Line	:
City	:	MONTICELLO
State	:	IL
Zip	:	61856-8058
Country	:	US
Telephone Number	:	217-233-3101
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3161
Country	:	US
Telephone Number	:	608-837-7325
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRADLEY GRANT
Credential	:	OD
Telephone Number	:	217-233-3101

Provider Enumeration Date	:	07/10/2023
Last Update Date	:	07/10/2023

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