Provider Demographics
NPI:1306016407
Name:LG OPTICAL ENTERPRISES
Entity Type:Organization
Organization Name:LG OPTICAL ENTERPRISES
Other - Org Name:TOTAL EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-692-8262
Mailing Address - Street 1:952 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2830
Mailing Address - Country:US
Mailing Address - Phone:605-692-8262
Mailing Address - Fax:605-692-9805
Practice Address - Street 1:952 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2830
Practice Address - Country:US
Practice Address - Phone:605-692-8262
Practice Address - Fax:605-692-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD05001593786886EST001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD111835OtherEYEMED
SD4997613OtherBLUE CROSS BLUE SHIELD
SD9226299OtherDAKOTA CARE
SD39879OtherAVESIS
SD9281452Medicaid