Provider Demographics
NPI:1528066651
Name:LAKE REGION EYE CENTER
Entity type:Organization
Organization Name:LAKE REGION EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNEIDERHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-763-7055
Mailing Address - Street 1:610 30TH AVE W STE 200
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-7055
Mailing Address - Fax:320-763-2572
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:STE 200
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-7055
Practice Address - Fax:320-763-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN355300134Medicaid
MN914218500Medicaid
MN597816500Medicaid
MN127518600Medicaid
MN428670300Medicaid
MN428670300Medicaid
MN410003486Medicare PIN
MN597816500Medicaid
MN355300134Medicaid
MN0801280001Medicare NSC
MNU73157Medicare UPIN
MNC03205Medicare ID - Type Unspecified
MNU37290Medicare UPIN
MNU98495Medicare UPIN