Provider Demographics
NPI:1619090073
Name:WEGNER VISION CLINIC, SC
Entity Type:Organization
Organization Name:WEGNER VISION CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-637-7917
Mailing Address - Street 1:1120 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3028
Mailing Address - Country:US
Mailing Address - Phone:262-637-7917
Mailing Address - Fax:262-637-6786
Practice Address - Street 1:1120 GROVE AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-3028
Practice Address - Country:US
Practice Address - Phone:262-637-7917
Practice Address - Fax:262-637-6786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5678080001Medicare NSC
WI000047555Medicare ID - Type UnspecifiedMEDICARE ID