Provider Demographics
NPI:1427292143
Name:LAKEVILLE FAMILY EYE CARE LLC
Entity type:Organization
Organization Name:LAKEVILLE FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-898-9588
Mailing Address - Street 1:17690 KENWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9764
Mailing Address - Country:US
Mailing Address - Phone:952-898-9588
Mailing Address - Fax:952-898-2030
Practice Address - Street 1:17690 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9764
Practice Address - Country:US
Practice Address - Phone:952-898-9588
Practice Address - Fax:952-898-2030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SUBURBAN EYE CARE SPECIALISTS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN499R7LAOtherBLUE CROSS BLUE SHIELD MN
MN2203175OtherUNITED HEALTH CARE
MN2823OtherMN LICENSE
MNA61971031584OtherPREFERRED ONE
MN202779692OtherVSP
MN1518037563OtherNPI
MN2203175OtherMEDICA
MNHP36326OtherHEALTHPARTNERS
MNMM1106447OtherDEA
MN499R7LAOtherBLUE CROSS BLUE SHIELD MN
MNHP36326OtherHEALTHPARTNERS