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General NPI Number Information
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NPI Number | 1285048322
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Entity Type | Organization
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Legal Business Name | LANCE ENGDAHL EYE CARE S.C.
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Dates
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Enumeration Date | 06/17/2014
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Last Update Date | 06/17/2014
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Provider Practice Location Address
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Address Line | 6658 ODANA RD
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City | MADISON
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State | WI
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Zip | 53719-1012
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Country | US
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Telephone | 608-829-3937
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Fax |
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Provider Business Mailing Address
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Address Line | 116 E LAKESIDE ST
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City | MADISON
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State | WI
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Zip | 53715-2028
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Country | US
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Telephone | 262-853-2664
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LANCE EDWARD ENGDAHL
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Credential | O.D.
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Telephone | 262-853-2664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2711-35
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License Number State | WI
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