Provider Demographics
NPI:1548413107
Name:FAMILY VISION CENTER OF LA CROSSE
Entity Type:Organization
Organization Name:FAMILY VISION CENTER OF LA CROSSE
Other - Org Name:RICHARD L. FOSS OD, FAMILY VISION CENTER OF TOMAH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WONDERLING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-788-4300
Mailing Address - Street 1:1825 N SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1683
Mailing Address - Country:US
Mailing Address - Phone:608-372-4664
Mailing Address - Fax:608-372-3021
Practice Address - Street 1:1825 N SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1683
Practice Address - Country:US
Practice Address - Phone:608-372-4664
Practice Address - Fax:608-372-3021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2949152W00000X
WI1466152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI387010300Medicaid
WI38563100Medicaid
WI387010300Medicaid
WIK100356809Medicare PIN
WI38563100Medicaid
WI0691570001Medicare NSC