MEDICARE: WEGNER VISION CLINIC, SC

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	2647	WI

General Provider Information

NPI Number	:	1619090073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEGNER VISION CLINIC, SC

Provider Business Mailing Address
First Line	:	1120 GROVE AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-3028
Country	:	US
Telephone Number	:	262-637-7917
Fax Number	:	262-637-6786

Provider Business Practice Location Address
First Line	:	1120 GROVE AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-3028
Country	:	US
Telephone Number	:	262-637-7917
Fax Number	:	262-637-6786

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. JON R WEGNER
Credential	:	O.D.
Telephone Number	:	262-637-7917

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	04/04/2012

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