Provider Demographics
NPI:1013165729
Name:EYE CLINIC OF WAUKESHA LLC
Entity Type:Organization
Organization Name:EYE CLINIC OF WAUKESHA LLC
Other - Org Name:KRISTOPHER KNOUS OD LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:262-549-2020
Mailing Address - Street 1:2426 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6905
Mailing Address - Country:US
Mailing Address - Phone:262-549-2020
Mailing Address - Fax:262-522-8117
Practice Address - Street 1:2426 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6905
Practice Address - Country:US
Practice Address - Phone:262-549-2020
Practice Address - Fax:262-522-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356432199OtherPERSONAL NPI
WI3946025OtherMEDICARE PROVIDER NUMBER
WI38625000Medicaid
WI3946025OtherMEDICARE PROVIDER NUMBER