Provider Demographics
NPI:1225791973
Name:EYES ON THE LAKE
Entity Type:Organization
Organization Name:EYES ON THE LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-850-1367
Mailing Address - Street 1:2134 S KINNICKINNIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1379
Mailing Address - Country:US
Mailing Address - Phone:414-293-1180
Mailing Address - Fax:414-293-1181
Practice Address - Street 1:2134 S KINNICKINNIC AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1379
Practice Address - Country:US
Practice Address - Phone:414-293-1180
Practice Address - Fax:414-293-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124478144Medicaid