Provider Demographics
NPI:1265847073
Name:LAKESHORE EYE CLINIC PC
Entity Type:Organization
Organization Name:LAKESHORE EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-789-1400
Mailing Address - Street 1:2500 7TH AVE S
Mailing Address - Street 2:217 STE
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1176
Mailing Address - Country:US
Mailing Address - Phone:906-789-1400
Mailing Address - Fax:906-789-3457
Practice Address - Street 1:2500 7TH AVE S
Practice Address - Street 2:217 STE
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1176
Practice Address - Country:US
Practice Address - Phone:906-789-1400
Practice Address - Fax:906-789-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B10059OtherBCBS
MI900B10059OtherBCBS