Provider Demographics
NPI: | 1144387077 |
---|---|
Name: | LANTZ OPTICAL CO |
Entity Type: | Organization |
Organization Name: | LANTZ OPTICAL CO |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | CASSANDRA |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | AMUNDSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 320-251-2820 |
Mailing Address - Street 1: | 900 WEST ST GERMAIN |
Mailing Address - Street 2: | |
Mailing Address - City: | ST CLOUD |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56301 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 320-251-2820 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 900 WEST ST GERMAIN |
Practice Address - Street 2: | |
Practice Address - City: | ST CLOUD |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56301 |
Practice Address - Country: | US |
Practice Address - Phone: | 320-251-2820 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-01-02 |
Last Update Date: | 2008-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332H00000X | Suppliers | Eyewear Supplier |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 291NOLA | Other | BLUE CROSS BLUE SHIELD OF MINNESOTA |
MN | 291NOLA | Other | BLUE CROSS BLUE SHIELD OF MINNESOTA |