Provider Demographics
NPI:1972798577
Name:CHRISTENSEN EYECARE PROFESSIONALS
Entity Type:Organization
Organization Name:CHRISTENSEN EYECARE PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:PHAM
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-893-4396
Mailing Address - Street 1:W143N6156 RED OAK CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-5895
Mailing Address - Country:US
Mailing Address - Phone:262-893-4396
Mailing Address - Fax:
Practice Address - Street 1:443 PEWAUKEE RD
Practice Address - Street 2:COSTCO OPTICAL
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5886
Practice Address - Country:US
Practice Address - Phone:262-956-6715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2803305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38609900Medicaid
WI38609900Medicaid