Provider Demographics
NPI:1467558536
Name:KNIGHT VISION & GLAUCOMA SPECIALISTS, INC.
Entity Type:Organization
Organization Name:KNIGHT VISION & GLAUCOMA SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOULANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-453-2534
Mailing Address - Street 1:7300 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4729
Mailing Address - Country:US
Mailing Address - Phone:414-453-6667
Mailing Address - Fax:414-774-5505
Practice Address - Street 1:7300 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4729
Practice Address - Country:US
Practice Address - Phone:414-453-6667
Practice Address - Fax:414-774-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2138-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38529800Medicaid
WIT62444Medicare UPIN
WI0299440001Medicare NSC
WI38529800Medicaid