Provider Demographics
NPI:1912032731
Name:GRANGE VISION CENTER, INC.
Entity Type:Organization
Organization Name:GRANGE VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WACLAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:414-281-4800
Mailing Address - Street 1:5312 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3724
Mailing Address - Country:US
Mailing Address - Phone:414-281-4800
Mailing Address - Fax:414-281-4891
Practice Address - Street 1:5312 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-3724
Practice Address - Country:US
Practice Address - Phone:414-281-4800
Practice Address - Fax:414-281-4891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1768152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38400800Medicaid
WI0236170001Medicare NSC
WI38400800Medicaid