Provider Demographics
NPI:1134515679
Name:LAKE MERRITT OPTOMETRY
Entity Type:Organization
Organization Name:LAKE MERRITT OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERENE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:NGIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-444-1969
Mailing Address - Street 1:1807 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1803
Mailing Address - Country:US
Mailing Address - Phone:510-444-1969
Mailing Address - Fax:
Practice Address - Street 1:1807 3RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-1803
Practice Address - Country:US
Practice Address - Phone:510-444-1969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11844T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty