Provider Demographics
NPI:1689291254
Name:LYNNE'S MOC, LLC
Entity Type:Organization
Organization Name:LYNNE'S MOC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-251-2020
Mailing Address - Street 1:512 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703
Mailing Address - Country:US
Mailing Address - Phone:608-251-2020
Mailing Address - Fax:
Practice Address - Street 1:512 STATE STREET
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703
Practice Address - Country:US
Practice Address - Phone:608-251-2020
Practice Address - Fax:608-251-5966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty