1285730911 NPI number — LAKESIDE OPTICAL

Table of content: (NPI 1285730911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285730911 NPI number — LAKESIDE OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE OPTICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285730911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 W SALE RD
Provider Second Line Business Mailing Address:
BLDG. F, STE. 3
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70605-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-433-3231
Provider Business Mailing Address Fax Number:
337-439-0185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 W SALE RD
Provider Second Line Business Practice Location Address:
BLDG. F, STE. 3
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70605-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-433-3231
Provider Business Practice Location Address Fax Number:
337-439-0185
Provider Enumeration Date:
09/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DYER
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
337-433-3231

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  015273 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)