Provider Demographics
NPI:1215066212
Name:DURAND OPTOMETRY CLINIC LLC DBA MONDOVI EYE AND OPTICAL
Entity type:Organization
Organization Name:DURAND OPTOMETRY CLINIC LLC DBA MONDOVI EYE AND OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-926-4273
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-0087
Mailing Address - Country:US
Mailing Address - Phone:715-926-4273
Mailing Address - Fax:
Practice Address - Street 1:129 S. EAU CLAIRE ST.
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-0087
Practice Address - Country:US
Practice Address - Phone:715-926-4273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5681910002OtherDMERC
2216527OtherMEDICA -EXAM
2100792OtherMEDICA- MATERIALS
WI38725600Medicaid
45861OtherSPECTERA
MN439K2MOOtherBCBS OF MN
MN439K2MOOtherBCBS OF MN