1629494703 NPI number — NORTH SHORE EYE HEALTH AND WELLNESS, SC

Table of content: (NPI 1629494703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629494703 NPI number — NORTH SHORE EYE HEALTH AND WELLNESS, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH SHORE EYE HEALTH AND WELLNESS, SC
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:
1629494703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N54W6135 MILL ST
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012-2021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-421-4412
Provider Business Mailing Address Fax Number:
262-421-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N54W6135 MILL ST
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
CEDARBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53012-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-421-4412
Provider Business Practice Location Address Fax Number:
262-421-4413
Provider Enumeration Date:
03/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
262-421-4412

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3226-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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