=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821220880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLSON EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2009
-----------------------------------------------------
Last Update Date | 08/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 US HWY 14 E
-----------------------------------------------------
City | RICHLAND CENTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53581-2996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-647-7914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 462 COMMERCE DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-5169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | ANGIE OLSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-239-6421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2773
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------