MEDICARE: LAUREN TA OD

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	2644	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811973605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN TA OD

Provider Business Mailing Address
First Line	:	428 W MAIN ST
Second Line	:	PO BOX 350
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-1902
Country	:	US
Telephone Number	:	608-437-3377
Fax Number	:	608-437-5063

Provider Business Practice Location Address
First Line	:	428 W MAIN ST
Second Line	:
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-1902
Country	:	US
Telephone Number	:	608-437-3377
Fax Number	:	608-437-5063

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

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/09/2010

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Directions to “ LAUREN TA OD” Practice Location

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