Provider Demographics
NPI:1003557133
Name:LAKESIDE VISION, PRUDENVILLE, PC
Entity Type:Organization
Organization Name:LAKESIDE VISION, PRUDENVILLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-366-7525
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-0020
Mailing Address - Country:US
Mailing Address - Phone:989-366-7525
Mailing Address - Fax:989-366-5405
Practice Address - Street 1:888 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9451
Practice Address - Country:US
Practice Address - Phone:989-366-7525
Practice Address - Fax:989-366-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty