Healthcare Provider Details

I. General information

NPI: 1710072939
Provider Name (Legal Business Name): SAMUELSON EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 WEST MAIN ST
MOUNT HOREB WI
53572-2103
US

IV. Provider business mailing address

428 WEST MAIN ST PO BOX 350
MOUNT HOREB WI
53572-2103
US

V. Phone/Fax

Practice location:
  • Phone: 608-437-3377
  • Fax: 608-437-5063
Mailing address:
  • Phone: 608-437-3377
  • Fax: 608-437-5063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: LAUREN TA-SAMUELSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 608-437-3377