Provider Demographics
NPI:1285048322
Name:LANCE ENGDAHL EYE CARE S.C.
Entity type:Organization
Organization Name:LANCE ENGDAHL EYE CARE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ENGDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-853-2664
Mailing Address - Street 1:116 E LAKESIDE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-2028
Mailing Address - Country:US
Mailing Address - Phone:262-853-2664
Mailing Address - Fax:
Practice Address - Street 1:6658 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1012
Practice Address - Country:US
Practice Address - Phone:608-829-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2711-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU89182Medicare UPIN