Provider Demographics
NPI:1699712067
Name:LAKESIDE OPTICAL INC
Entity type:Organization
Organization Name:LAKESIDE OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:727-398-7500
Mailing Address - Street 1:6595 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-6314
Mailing Address - Country:US
Mailing Address - Phone:727-398-7500
Mailing Address - Fax:727-398-4851
Practice Address - Street 1:6595 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-6314
Practice Address - Country:US
Practice Address - Phone:727-398-7500
Practice Address - Fax:727-398-4851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE 0000300156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD7661OtherBC/BS FL SUPPLIER NUMBER
C08421572OtherPALMETTO EDI SUBMITTER #
FL0651580001Medicare NSC