Provider Demographics
NPI:1679316996
Name:RADIANT EYES LLC
Entity type:Organization
Organization Name:RADIANT EYES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:SHIRLEY
Authorized Official - Last Name:AVGOULAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-490-0275
Mailing Address - Street 1:197 S GOLDEN VISTA CT
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8635
Mailing Address - Country:US
Mailing Address - Phone:262-490-0275
Mailing Address - Fax:
Practice Address - Street 1:W248N5233 EXECUTIVE DR UNIT 200
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-4318
Practice Address - Country:US
Practice Address - Phone:262-304-0080
Practice Address - Fax:262-304-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty