Provider Demographics
NPI:1245449644
Name:MILTON & EDGERTON VISION CENTERS, LLC
Entity type:Organization
Organization Name:MILTON & EDGERTON VISION CENTERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:NICOLE KASTING
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-868-4651
Mailing Address - Street 1:641 E SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-3719
Mailing Address - Country:US
Mailing Address - Phone:608-868-4651
Mailing Address - Fax:608-868-9142
Practice Address - Street 1:641 E SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WI
Practice Address - Zip Code:53563-3719
Practice Address - Country:US
Practice Address - Phone:608-868-4651
Practice Address - Fax:608-884-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38514300Medicaid
WI38514300Medicaid
WI87407Medicare PIN