Provider Demographics
NPI:1013461771
Name:VISION MART, INC
Entity Type:Organization
Organization Name:VISION MART, INC
Other - Org Name:VISION MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-462-1300
Mailing Address - Street 1:12000 W CARMEN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-2116
Mailing Address - Country:US
Mailing Address - Phone:414-462-1300
Mailing Address - Fax:414-462-4780
Practice Address - Street 1:130 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1206
Practice Address - Country:US
Practice Address - Phone:414-962-6744
Practice Address - Fax:414-962-6746
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISION MART, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3845000Medicaid
WI3845000Medicaid