Provider Demographics
NPI:1003434622
Name:LOST LAKE OPTICAL COMPANY
Entity Type:Organization
Organization Name:LOST LAKE OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:612-670-8887
Mailing Address - Street 1:5240 SHADY ISLAND CIR
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9222
Mailing Address - Country:US
Mailing Address - Phone:612-670-8887
Mailing Address - Fax:952-474-1933
Practice Address - Street 1:5240 SHADY ISLAND CIR
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-9222
Practice Address - Country:US
Practice Address - Phone:612-670-8887
Practice Address - Fax:952-474-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center