1508902164 NPI number — LAKES REGION OPTICIANS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508902164 NPI number — LAKES REGION OPTICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKES REGION OPTICIANS INC
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:
1508902164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1750
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOLFEBORO
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03894-1750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-569-5442
Provider Business Mailing Address Fax Number:
603-569-4378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 S MAIN ST
Provider Second Line Business Practice Location Address:
MEDICAL ARTS CENTER
Provider Business Practice Location Address City Name:
WOLFEBORO
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03894-4411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-569-5442
Provider Business Practice Location Address Fax Number:
603-569-4378
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IRVING
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
603-569-5442

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30010616 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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