Provider Demographics
NPI:1568863496
Name:VISION SOURCE SPECIALISTS, PROF. L.L.C.
Entity Type:Organization
Organization Name:VISION SOURCE SPECIALISTS, PROF. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTENHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-399-3937
Mailing Address - Street 1:318 MOUNT RUSHMORE RD
Mailing Address - Street 2:STE A
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2769
Mailing Address - Country:US
Mailing Address - Phone:605-399-3937
Mailing Address - Fax:605-399-5910
Practice Address - Street 1:318 MOUNT RUSHMORE RD
Practice Address - Street 2:STE A
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2769
Practice Address - Country:US
Practice Address - Phone:605-399-3937
Practice Address - Fax:605-399-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD0553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1679653240OtherNPI
SD1124109848OtherNPI
SD1154390573OtherNPI
SD1245344001OtherNPI