Provider Demographics
NPI:1164448627
Name:CROSSROADS OPTOMETRIC CLINIC, INC.
Entity Type:Organization
Organization Name:CROSSROADS OPTOMETRIC CLINIC, INC.
Other - Org Name:LAKESIDE FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DAWSON-CLAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-447-2020
Mailing Address - Street 1:16250 DULUTH AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2883
Mailing Address - Country:US
Mailing Address - Phone:952-447-2020
Mailing Address - Fax:952-447-2322
Practice Address - Street 1:16250 DULUTH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2883
Practice Address - Country:US
Practice Address - Phone:952-447-2020
Practice Address - Fax:952-447-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0001425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN92364OtherPREFERRED ONE
MN2123989OtherMEDICA DME
MN3C258CROtherBCBS DME
MN4825OtherHEALTHPARTNERS
MN51154HIOtherBCBS-MN
MN2223987OtherMEDICA
MN51154HIOtherBCBS-MN
MN=========OtherSELECT CARE
MN0314340001Medicare NSC
MN92364OtherPREFERRED ONE