Provider Demographics
NPI:1710072939
Name:SAMUELSON EYECARE LLC
Entity Type:Organization
Organization Name:SAMUELSON EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:TA-SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-437-3377
Mailing Address - Street 1:428 WEST MAIN ST
Mailing Address - Street 2:PO BOX 350
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-2103
Mailing Address - Country:US
Mailing Address - Phone:608-437-3377
Mailing Address - Fax:608-437-5063
Practice Address - Street 1:428 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-2103
Practice Address - Country:US
Practice Address - Phone:608-437-3377
Practice Address - Fax:608-437-5063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38714000Medicaid
WI1244490001Medicare NSC
WI47350Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER