MEDICARE: DR. SANDRA MARIE HUENINK OD

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	3415-35	WI

General Provider Information

NPI Number	:	1902258742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA MARIE HUENINK OD

Provider Business Mailing Address
First Line	:	3278 MAIN ST
Second Line	:	PO BOX 165
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-9719
Fax Number	:	262-642-2228

Provider Business Practice Location Address
First Line	:	3278 MAIN ST
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-9719
Fax Number	:	262-642-2228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2016
Last Update Date	:	07/05/2016

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