Provider Demographics
NPI:1629494703
Name:NORTH SHORE EYE HEALTH AND WELLNESS, SC
Entity Type:Organization
Organization Name:NORTH SHORE EYE HEALTH AND WELLNESS, SC
Other - Org Name:NORTH SHORE EYE HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:262-421-4412
Mailing Address - Street 1:N54W6135 MILL ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2021
Mailing Address - Country:US
Mailing Address - Phone:262-421-4412
Mailing Address - Fax:262-421-4413
Practice Address - Street 1:N54W6135 MILL ST
Practice Address - Street 2:SUITE 700
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2021
Practice Address - Country:US
Practice Address - Phone:262-421-4412
Practice Address - Fax:262-421-4413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3226-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty