MEDICARE: KNIGHT VISION & GLAUCOMA SPECIALISTS, INC.

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	2138-035	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467558536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNIGHT VISION & GLAUCOMA SPECIALISTS, INC.

Provider Business Mailing Address
First Line	:	7300 W GREENFIELD AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-4729
Country	:	US
Telephone Number	:	414-453-6667
Fax Number	:	414-774-5505

Provider Business Practice Location Address
First Line	:	7300 W GREENFIELD AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-4729
Country	:	US
Telephone Number	:	414-453-6667
Fax Number	:	414-774-5505

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. DAWN M. BOULANGER
Credential	:
Telephone Number	:	414-453-2534

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	03/03/2009

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