Basic Information
| Provider Information | |||||||||
| NPI: | 1215976352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUNDERSEN CLINIC, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GL VISION CENTER - WHITEHALL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087827300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18606 ERVIN ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547738613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087827300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADANK | ||||||||
| AuthorizedOfficialFirstName: | KARI | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 6087758025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GUNDERSEN CLINIC, LTD. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.