Provider Demographics
NPI:1104219039
Name:STATELINE VISION CENTER LLC
Entity Type:Organization
Organization Name:STATELINE VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOSEPHS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-325-7200
Mailing Address - Street 1:250 N 18TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1482
Mailing Address - Country:US
Mailing Address - Phone:608-325-7200
Mailing Address - Fax:
Practice Address - Street 1:250 N 18TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1482
Practice Address - Country:US
Practice Address - Phone:920-216-3133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty