Provider Demographics
NPI:1073663704
Name:LAKESHORE VISION CENTERS LTD
Entity Type:Organization
Organization Name:LAKESHORE VISION CENTERS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-487-2020
Mailing Address - Street 1:1217 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216
Mailing Address - Country:US
Mailing Address - Phone:920-388-2020
Mailing Address - Fax:920-388-3594
Practice Address - Street 1:1217 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216
Practice Address - Country:US
Practice Address - Phone:920-388-2020
Practice Address - Fax:920-388-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047383OtherMEDICARE PTAN
CS0632Medicare PIN
WI000047383OtherMEDICARE PTAN