Provider Demographics
NPI:1235140138
Name:LAKE OPTICAL, INC.
Entity Type:Organization
Organization Name:LAKE OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWINSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-587-0901
Mailing Address - Street 1:2 W GRAND AVE
Mailing Address - Street 2:SUITE107
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1262
Mailing Address - Country:US
Mailing Address - Phone:847-587-0901
Mailing Address - Fax:847-587-8157
Practice Address - Street 1:2 W GRAND AVE
Practice Address - Street 2:SUITE107
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1262
Practice Address - Country:US
Practice Address - Phone:847-587-0901
Practice Address - Fax:847-587-8157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty