Provider Demographics
NPI:1275799629
Name:MAYVILLE VISION CENTER, INC.
Entity Type:Organization
Organization Name:MAYVILLE VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CASSANDRE
Authorized Official - Middle Name:BEZOLD
Authorized Official - Last Name:HETZER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-387-3180
Mailing Address - Street 1:935 HORICON ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1428
Mailing Address - Country:US
Mailing Address - Phone:920-387-3180
Mailing Address - Fax:920-387-9636
Practice Address - Street 1:935 HORICON ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1428
Practice Address - Country:US
Practice Address - Phone:920-387-3180
Practice Address - Fax:920-387-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 2915-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38617900Medicaid
WI47925Medicare PIN
WIU93953Medicare UPIN
WI38617900Medicaid