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General NPI Number Information
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NPI Number | 1801122148
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Entity Type | Organization
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Legal Business Name | PALM VISION, LLC
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Dates
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Enumeration Date | 10/21/2009
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Last Update Date | 10/21/2009
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Provider Practice Location Address
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Address Line | 3800 STATE ROAD 16 SUITE 103
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City | LA CROSSE
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State | WI
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Zip | 54601-1826
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Country | US
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Telephone | 608-781-2020
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Fax | 608-781-2445
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Provider Business Mailing Address
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Address Line | 3800 STATE ROAD 16 SUITE 103
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City | LA CROSSE
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State | WI
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Zip | 54601-1826
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Country | US
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Telephone | 608-781-2020
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Fax | 608-781-2445
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Authorized Official
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Title or Position | OWNER
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Name | ANDREW PALM
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Credential | O.D.
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Telephone | 608-317-3092
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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 | 2939-035
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License Number State | WI
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