1306016407 NPI number — LG OPTICAL ENTERPRISES

Table of content: (NPI 1306016407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306016407 NPI number — LG OPTICAL ENTERPRISES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LG OPTICAL ENTERPRISES
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:
6
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:
1306016407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
952 22ND AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57006-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-692-8262
Provider Business Mailing Address Fax Number:
605-692-9805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
952 22ND AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-692-8262
Provider Business Practice Location Address Fax Number:
605-692-9805
Provider Enumeration Date:
03/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GANNON
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
605-692-8262

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  05001593786886EST001 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111835 . This is a "EYEMED" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4997613 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9226299 . This is a "DAKOTA CARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 39879 . This is a "AVESIS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9281452 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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