Provider Demographics
NPI:1285730911
Name:LAKESIDE OPTICAL
Entity type:Organization
Organization Name:LAKESIDE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-433-3231
Mailing Address - Street 1:1920 W SALE RD
Mailing Address - Street 2:BLDG. F, STE. 3
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2400
Mailing Address - Country:US
Mailing Address - Phone:337-433-3231
Mailing Address - Fax:337-439-0185
Practice Address - Street 1:1920 W SALE RD
Practice Address - Street 2:BLDG. F, STE. 3
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2400
Practice Address - Country:US
Practice Address - Phone:337-433-3231
Practice Address - Fax:337-439-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015273332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5839920001Medicare NSC