MEDICARE: SOREN A. NYWALL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1687-035	WI

General Provider Information

NPI Number	:	1396738563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOREN A. NYWALL O.D.

Provider Business Mailing Address
First Line	:	1220 PARKWOOD DRIVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-5488
Country	:	US
Telephone Number	:	715-421-2111
Fax Number	:	715-421-2123

Provider Business Practice Location Address
First Line	:	1220 PARKWOOD DRIVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-5488
Country	:	US
Telephone Number	:	715-421-2111
Fax Number	:	715-421-2123

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	05/13/2009

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