Provider Demographics
NPI:1255591236
Name:DR WAGNER SOUTHRIDGE OPTICAL LLC
Entity type:Organization
Organization Name:DR WAGNER SOUTHRIDGE OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-855-0469
Mailing Address - Street 1:5300 S 76TH ST
Mailing Address - Street 2:STE 690
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1102
Mailing Address - Country:US
Mailing Address - Phone:414-855-0469
Mailing Address - Fax:414-855-0492
Practice Address - Street 1:5300 S 76TH ST
Practice Address - Street 2:STE 690
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1102
Practice Address - Country:US
Practice Address - Phone:414-855-0469
Practice Address - Fax:414-855-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4800030001Medicare NSC
WIT21464Medicare UPIN
WI000427289Medicare PIN