Provider Demographics
NPI:1558445197
Name:SE PROFESSIONALS SC
Entity Type:Organization
Organization Name:SE PROFESSIONALS SC
Other - Org Name:PREMIER VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KING
Authorized Official - Last Name:AYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-467-7000
Mailing Address - Street 1:8693 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-351-2020
Mailing Address - Fax:414-351-2031
Practice Address - Street 1:8693 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-351-2020
Practice Address - Fax:414-351-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047200Medicare PIN
0565870001Medicare NSC