Provider Demographics
NPI:1508242256
Name:ADVANCED FOCUS EYECARE LLC
Entity Type:Organization
Organization Name:ADVANCED FOCUS EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BARDENWERPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-366-6370
Mailing Address - Street 1:1116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-1923
Mailing Address - Country:US
Mailing Address - Phone:262-366-6370
Mailing Address - Fax:
Practice Address - Street 1:1116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1923
Practice Address - Country:US
Practice Address - Phone:262-366-6370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325735152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty