Healthcare Provider Details

I. General information

NPI: 1396738563
Provider Name (Legal Business Name): SOREN A. NYWALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 PARKWOOD DRIVE
WISCONSIN RAPIDS WI
54494-5488
US

IV. Provider business mailing address

1220 PARKWOOD DRIVE
WISCONSIN RAPIDS WI
54494-5488
US

V. Phone/Fax

Practice location:
  • Phone: 715-421-2111
  • Fax: 715-421-2123
Mailing address:
  • Phone: 715-421-2111
  • Fax: 715-421-2123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1687-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: