1346525573 NPI number — VISION MART, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346525573 NPI number — VISION MART, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION MART, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346525573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12000 W CARMEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53225-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-462-1300
Provider Business Mailing Address Fax Number:
414-462-4780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2476 S ONEIDA ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54304-5289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-965-0260
Provider Business Practice Location Address Fax Number:
920-965-0262
Provider Enumeration Date:
10/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DICKMAN
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
414-462-1300

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3845000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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