Provider Demographics
NPI:1891068599
Name:PETROU-HAEFS EYECARE, LLC
Entity Type:Organization
Organization Name:PETROU-HAEFS EYECARE, LLC
Other - Org Name:PETROU EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:414-839-8379
Mailing Address - Street 1:7040 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3885
Mailing Address - Country:US
Mailing Address - Phone:414-839-8379
Mailing Address - Fax:
Practice Address - Street 1:7040 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 420
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3885
Practice Address - Country:US
Practice Address - Phone:414-839-8379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-12
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2387-035261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI385755400Medicaid
0000287994Medicare PIN
U35166Medicare UPIN
0866110001Medicare NSC