Provider Demographics
NPI:1407801087
Name:AEG WISCONSIN PROFESSIONAL LTD
Entity Type:Organization
Organization Name:AEG WISCONSIN PROFESSIONAL LTD
Other - Org Name:CHRISTENSON VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6206
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:2215 VINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-5802
Practice Address - Country:US
Practice Address - Phone:715-381-1234
Practice Address - Fax:314-741-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT97118Medicare UPIN
WIU98308Medicare UPIN
WI0842880001Medicare NSC