Provider Demographics
NPI:1023138922
Name:WEST BEND OPTICAL, INC
Entity type:Organization
Organization Name:WEST BEND OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-338-1800
Mailing Address - Street 1:3720 W. WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8406
Mailing Address - Country:US
Mailing Address - Phone:262-338-1800
Mailing Address - Fax:262-338-1947
Practice Address - Street 1:3720 W. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8406
Practice Address - Country:US
Practice Address - Phone:262-338-1800
Practice Address - Fax:262-338-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1756152W00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4928780001Medicare NSC
WIWI1594Medicare PIN