Provider Demographics
NPI:1003932088
Name:CONGDON OPTOMETRY INC
Entity Type:Organization
Organization Name:CONGDON OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2101
Mailing Address - Street 1:3003 CLEVELAND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3761
Mailing Address - Country:US
Mailing Address - Phone:715-732-2101
Mailing Address - Fax:
Practice Address - Street 1:3003 CLEVELAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
87906Medicare ID - Type UnspecifiedIDENTIFIER NUMBER
0566130001Medicare NSC