Provider Demographics
NPI:1336316249
Name:LC OPTOMETRIC PC
Entity Type:Organization
Organization Name:LC OPTOMETRIC PC
Other - Org Name:LENSCRAFTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUISNESS MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:TROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-354-9505
Mailing Address - Street 1:1260 BROOKDALE DRIVE
Mailing Address - Street 2:BROOKDALE CENTER
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430
Mailing Address - Country:US
Mailing Address - Phone:763-560-9239
Mailing Address - Fax:
Practice Address - Street 1:12131 ELM CREEK BLVD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7093
Practice Address - Country:US
Practice Address - Phone:763-416-1983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN864687200Medicaid