Provider Demographics
NPI:1568217719
Name:MAYVILLE VISION
Entity Type:Organization
Organization Name:MAYVILLE VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:920-387-3180
Mailing Address - Street 1:935 HORICON ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1428
Mailing Address - Country:US
Mailing Address - Phone:920-387-3180
Mailing Address - Fax:920-387-9636
Practice Address - Street 1:935 HORICON ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1428
Practice Address - Country:US
Practice Address - Phone:920-387-3180
Practice Address - Fax:920-387-9636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYVILLE VISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier