Provider Demographics
NPI:1992755920
Name:LAKES AREA EYECARE, INC.
Entity type:Organization
Organization Name:LAKES AREA EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:GUNNARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-2929
Mailing Address - Street 1:7734 EXCELSIOR RD. N.
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-829-2929
Mailing Address - Fax:218-829-4747
Practice Address - Street 1:7734 EXCELSIOR RD. N.
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-829-2929
Practice Address - Fax:218-829-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1980152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02828Medicare UPIN