Provider Demographics
NPI:1568445062
Name:EYE SURGERY & LASER CENTER OF WISCONSIN LLC
Entity Type:Organization
Organization Name:EYE SURGERY & LASER CENTER OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNNELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CASC
Authorized Official - Phone:414-773-4662
Mailing Address - Street 1:10200 W INNOVATION DRIVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4825
Mailing Address - Country:US
Mailing Address - Phone:414-302-9196
Mailing Address - Fax:414-773-4668
Practice Address - Street 1:10200 W INNOVATION DR
Practice Address - Street 2:SUITE 700
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4825
Practice Address - Country:US
Practice Address - Phone:414-302-9196
Practice Address - Fax:414-773-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41910800Medicaid
WI41910800Medicaid
WI41910800Medicaid