Provider Demographics
NPI:1255477881
Name:LAKES REGION OPTICIANS INC
Entity Type:Organization
Organization Name:LAKES REGION OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-524-2050
Mailing Address - Street 1:212 PROUTY DR
Mailing Address - Street 2:BIRCHWOOD BUILDING PO BOX 692
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-9851
Mailing Address - Country:US
Mailing Address - Phone:802-334-7001
Mailing Address - Fax:802-334-7001
Practice Address - Street 1:212 PROUTY DR
Practice Address - Street 2:BIRCHWOOD BUILDING
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9851
Practice Address - Country:US
Practice Address - Phone:802-334-7001
Practice Address - Fax:802-334-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006611Medicaid
VT0339530001Medicare ID - Type UnspecifiedRETAIL DISPENSING OPTICIA