Provider Demographics
NPI:1780198515
Name:OPTICAL FASHIONS LTD
Entity Type:Organization
Organization Name:OPTICAL FASHIONS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:EKHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-782-7127
Mailing Address - Street 1:2104 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3046
Mailing Address - Country:US
Mailing Address - Phone:608-782-7127
Mailing Address - Fax:608-782-7124
Practice Address - Street 1:814 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9632
Practice Address - Country:US
Practice Address - Phone:608-782-7127
Practice Address - Fax:608-399-3097
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTICAL FASHIONS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2705152W00000X
WI3116152W00000X
WI3129152W00000X
WI3359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38709300Medicaid
WI100020764Medicaid
WI38602800Medicaid
WI38645900Medicaid
WI100039841Medicaid