Provider Demographics
NPI:1356444798
Name:SODERBERG EYE CARE CENTER
Entity Type:Organization
Organization Name:SODERBERG EYE CARE CENTER
Other - Org Name:DENNIS R. SODERBERG O.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:SODERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-265-7127
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54013-0097
Mailing Address - Country:US
Mailing Address - Phone:715-265-7127
Mailing Address - Fax:715-265-4238
Practice Address - Street 1:124 OAK STREET
Practice Address - Street 2:
Practice Address - City:GLENWOOD CITY
Practice Address - State:WI
Practice Address - Zip Code:54013
Practice Address - Country:US
Practice Address - Phone:715-265-7127
Practice Address - Fax:715-265-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38501900Medicaid
MN92533SOOtherBCBS
WI38501900Medicaid
WI38501900Medicaid
WI0699180002Medicare NSC
T63371Medicare UPIN