Provider Demographics
NPI:1851670921
Name:SAUKVILLE FAMILY EYE CENTER LLC
Entity type:Organization
Organization Name:SAUKVILLE FAMILY EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNOUS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-352-7907
Mailing Address - Street 1:935 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2618
Practice Address - Country:US
Practice Address - Phone:262-352-7907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38628400Medicaid
WI38628400Medicaid