MEDICARE: MYEYEDR OPTOMETRY OF 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	:	1851992341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYEYEDR OPTOMETRY OF WISCONSIN, LLC

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	2644 N 8TH ST
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53083-4921
Country	:	US
Telephone Number	:	920-458-3312
Fax Number	:	920-458-6827

Authorized Official
Title or Position	:	SECRETARY
Name	:	SUE DOWNES
Credential	:
Telephone Number	:	703-847-8899

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	05/24/2022

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