Provider Demographics
NPI:1396423273
Name:EYE WISCONSIN LLC
Entity type:Organization
Organization Name:EYE WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-233-3101
Mailing Address - Street 1:1090 BUCKS POND RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-8058
Mailing Address - Country:US
Mailing Address - Phone:217-233-3101
Mailing Address - Fax:
Practice Address - Street 1:1721 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3161
Practice Address - Country:US
Practice Address - Phone:608-837-7325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE WISCONSIN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty