Provider Demographics
NPI:1801122148
Name:PALM VISION, LLC
Entity type:Organization
Organization Name:PALM VISION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-317-3092
Mailing Address - Street 1:3800 STATE ROAD 16
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-1826
Mailing Address - Country:US
Mailing Address - Phone:608-781-2020
Mailing Address - Fax:608-781-2445
Practice Address - Street 1:3800 STATE ROAD 16
Practice Address - Street 2:SUITE 103
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-1826
Practice Address - Country:US
Practice Address - Phone:608-781-2020
Practice Address - Fax:608-781-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2939-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000687961Medicare UPIN