Provider Demographics
NPI:1154518967
Name:FAMILY VISION CENTER OF LA CROSSE
Entity type:Organization
Organization Name:FAMILY VISION CENTER OF LA CROSSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WONDERLING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-788-4300
Mailing Address - Street 1:3424 MORMON COULEE RD
Mailing Address - Street 2:STE A
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6750
Mailing Address - Country:US
Mailing Address - Phone:608-788-4300
Mailing Address - Fax:608-788-4325
Practice Address - Street 1:3424 MORMON COULEE RD
Practice Address - Street 2:STE A
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6750
Practice Address - Country:US
Practice Address - Phone:608-788-4300
Practice Address - Fax:608-788-4325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100356809Medicare PIN
WI0691570002Medicare NSC
WI000047470Medicare PIN