Provider Demographics
NPI:1053447474
Name:SHOREWOOD OPTICIANS
Entity Type:Organization
Organization Name:SHOREWOOD OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:FABRIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-332-0606
Mailing Address - Street 1:5150 N PORT WASHINGTON RD
Mailing Address - Street 2:#251
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5474
Mailing Address - Country:US
Mailing Address - Phone:414-332-0606
Mailing Address - Fax:414-967-3604
Practice Address - Street 1:5150 N PORT WASHINGTON RD
Practice Address - Street 2:#251
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-5474
Practice Address - Country:US
Practice Address - Phone:414-332-0606
Practice Address - Fax:414-967-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier