Provider Demographics
NPI:1134272388
Name:REVERIE OPTIQUE
Entity type:Organization
Organization Name:REVERIE OPTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-786-4144
Mailing Address - Street 1:2205 N CALHOUN RD STE 16
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5062
Mailing Address - Country:US
Mailing Address - Phone:262-786-4144
Mailing Address - Fax:262-786-4729
Practice Address - Street 1:2205 N CALHOUN RD STE 16
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5062
Practice Address - Country:US
Practice Address - Phone:262-786-4144
Practice Address - Fax:262-786-4729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2942152W00000X
WI1718152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38714200Medicaid
WI0554750002Medicare NSC
WI000047320Medicare PIN