Provider Demographics
NPI:1780053595
Name:PEWAUKEE VISION SC
Entity type:Organization
Organization Name:PEWAUKEE VISION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-892-2691
Mailing Address - Street 1:1111 DELAFIELD ST STE 212
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3403
Mailing Address - Country:US
Mailing Address - Phone:262-521-9383
Mailing Address - Fax:262-547-1815
Practice Address - Street 1:1111 DELAFIELD ST STE 212
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3403
Practice Address - Country:US
Practice Address - Phone:262-521-9383
Practice Address - Fax:262-547-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty