Provider Demographics
NPI:1972723716
Name:NORTHERN SIGHT VISION CLINIC, LLC
Entity type:Organization
Organization Name:NORTHERN SIGHT VISION CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST / CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STROMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-453-3636
Mailing Address - Street 1:318 N. 6TH STREET,
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487
Mailing Address - Country:US
Mailing Address - Phone:715-453-3636
Mailing Address - Fax:715-453-3389
Practice Address - Street 1:318 N. 6TH STREET
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487
Practice Address - Country:US
Practice Address - Phone:715-453-3636
Practice Address - Fax:715-453-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2911152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38564600Medicaid
WI38618200Medicaid
WI38564600Medicaid
WI87460Medicare PIN
WI6018690002Medicare NSC
WI87460Medicare PIN