Provider Demographics
NPI:1639217730
Name:WISCONSIN VISION, INC
Entity Type:Organization
Organization Name:WISCONSIN VISION, INC
Other - Org Name:HEARTLAND VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HORNDASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-432-2005
Mailing Address - Street 1:16800 WEST CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:262-432-2006
Practice Address - Street 1:3972 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6812
Practice Address - Country:US
Practice Address - Phone:260-434-1998
Practice Address - Fax:260-436-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
02855OtherSPECTERA PROVIDER NO,
58256OtherDAVIS VISION PROVIDER NO.
02855OtherSPECTERA PROVIDER NO,
58256OtherDAVIS VISION PROVIDER NO.