Provider Demographics
NPI:1437485125
Name:GREAT LAKES FAMILY VISION SC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY VISION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:NATALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-268-2007
Mailing Address - Street 1:289 E GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2006
Mailing Address - Country:US
Mailing Address - Phone:262-268-2007
Mailing Address - Fax:262-268-8257
Practice Address - Street 1:289 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2006
Practice Address - Country:US
Practice Address - Phone:262-268-2007
Practice Address - Fax:262-268-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2716035332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier