Provider Demographics
NPI:1164597225
Name:LAKEVIEW VISION CENTER, LLC
Entity Type:Organization
Organization Name:LAKEVIEW VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:KAPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:541-947-3357
Mailing Address - Street 1:628 N 1ST ST STE C
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1506
Mailing Address - Country:US
Mailing Address - Phone:541-947-3357
Mailing Address - Fax:541-947-3368
Practice Address - Street 1:628 N 1ST ST STE C
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1506
Practice Address - Country:US
Practice Address - Phone:541-947-3357
Practice Address - Fax:541-947-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR961ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023632Medicaid
OR023632Medicaid
OR4850260001Medicare NSC
ORR116766Medicare ID - Type Unspecified