Provider Demographics
NPI:1659332823
Name:THE EYE GROUP SC
Entity Type:Organization
Organization Name:THE EYE GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGENAIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-542-7113
Mailing Address - Street 1:3228 TURNBERRY OAK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3969
Mailing Address - Country:US
Mailing Address - Phone:262-542-7113
Mailing Address - Fax:262-542-9439
Practice Address - Street 1:3228 TURNBERRY OAK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3969
Practice Address - Country:US
Practice Address - Phone:262-542-7113
Practice Address - Fax:262-542-9439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2760-035152W00000X, 152W00000X
WI2704-035152W00000X
WI1297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDE9562OtherPALMETTO GBA-RAILROAD MEDICARE
WIDE9562OtherPALMETTO GBA-RAILROAD MEDICARE
WI000068762Medicare ID - Type Unspecified
WIU77740Medicare UPIN
WI5291780001Medicare NSC
WI38722800Medicaid