Provider Demographics
NPI:1972871572
Name:BADGER VISION CENTER, LLC
Entity Type:Organization
Organization Name:BADGER VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISREGARDED ENTITY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAISDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:414-453-7020
Mailing Address - Street 1:2505 N MAYFAIR RD
Mailing Address - Street 2:STE 100
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1404
Mailing Address - Country:US
Mailing Address - Phone:414-453-7020
Mailing Address - Fax:414-453-9980
Practice Address - Street 1:2505 N MAYFAIR RD
Practice Address - Street 2:STE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1404
Practice Address - Country:US
Practice Address - Phone:414-453-7020
Practice Address - Fax:414-453-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4687710001OtherDME
WIMB0610736OtherDEA
WIMB0610736OtherDEA
U36977Medicare UPIN