Provider Demographics
NPI:1356704787
Name:LUNDBERG, RACHEL MARIE (OD)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MARIE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6520 LUMBERJACK GUY ROAD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:
Practice Address - Street 1:N6520 LUMBERJACK GUY RD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5405
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI3429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program