Provider Demographics
NPI:1366491227
Name:VISION MART INC
Entity Type:Organization
Organization Name:VISION MART INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-462-1300
Mailing Address - Street 1:12000 W CARMEN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-2116
Mailing Address - Country:US
Mailing Address - Phone:414-462-1300
Mailing Address - Fax:
Practice Address - Street 1:12000 W CARMEN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-2116
Practice Address - Country:US
Practice Address - Phone:414-462-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38450000Medicaid