Provider Demographics
NPI:1609839497
Name:EYE PROSTHETICS OF WISCONSIN
Entity type:Organization
Organization Name:EYE PROSTHETICS OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCULARIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYNES
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:262-754-3681
Mailing Address - Street 1:13255 W BLUEMOUND RD
Mailing Address - Street 2:101
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6245
Mailing Address - Country:US
Mailing Address - Phone:262-754-3681
Mailing Address - Fax:
Practice Address - Street 1:13255 W BLUEMOUND RD
Practice Address - Street 2:101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6245
Practice Address - Country:US
Practice Address - Phone:262-754-3681
Practice Address - Fax:262-754-3682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41731500Medicaid
WI4687050002Medicare ID - Type Unspecified