Eye Clinic of Waukesha LLC

Primary specialty

OptometristTaxonomy code 152W00000X

License

2999 Issued in WI

Legal business name

EYE CLINIC OF WAUKESHA LLC

Practice address

2426 N Grandview Blvd
Suite D
Waukesha, WI 53188-6905

Phone

(262) 549-2020

Fax

(262) 522-8117

NPI assigned

Sep 5, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Genni Mahoney, OPTICIAN

Title

Owner

Phone

(262) 549-2020

Specialties & licenses 1

Addresses

Other identifiers 3

Other names 1

• Kristopher Knous OD LLC Former legal business name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1220572800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1263513600000",
    "number": "1013165729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2426 N GRANDVIEW BLVD",
            "address_2": "SUITE D",
            "city": "WAUKESHA",
            "state": "WI",
            "postal_code": "531886905",
            "telephone_number": "262-549-2020",
            "fax_number": "262-522-8117"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2426 N GRANDVIEW BLVD",
            "address_2": "SUITE D",
            "city": "WAUKESHA",
            "state": "WI",
            "postal_code": "531886905",
            "telephone_number": "262-549-2020",
            "fax_number": "262-522-8117"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EYE CLINIC OF WAUKESHA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-09-05",
        "last_updated": "2010-01-15",
        "status": "A",
        "authorized_official_last_name": "MAHONEY",
        "authorized_official_first_name": "GENNI",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "262-549-2020",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "OPTICIAN"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "2999",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PERSONAL NPI",
            "identifier": "1356432199",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER NUMBER",
            "identifier": "3946025",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38625000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kristopher Knous OD LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Amber L Evonovich, RDH
• Jillian Louise Ewing Haas, M.D.
• Albert Charles Exner, D.D.S.
• Emma Louise Exner, SAC-IT, CSW
• Thomas Exner, D.D.S.
• Nathaniel D Fagan-Duerr, MSN, APNP, FNP-C
• Allison Fahey, APNP
• Joseph L Fahl, D.D.S.
• Kay Andrea Fahl, RDH
• Melissa Fairbank

• Optometrist in Waukesha, WI
• Providers in Waukesha, WI by specialty
• Optometrist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.