Provider Demographics
NPI:1487682126
Name:LAKES OPTOMETRY CLINIC PLLC
Entity Type:Organization
Organization Name:LAKES OPTOMETRY CLINIC PLLC
Other - Org Name:LAKES EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:FEMRITE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST
Authorized Official - Phone:320-685-5400
Mailing Address - Street 1:308 5TH AVE S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-2343
Mailing Address - Country:US
Mailing Address - Phone:320-685-5400
Mailing Address - Fax:
Practice Address - Street 1:308 5TH AVE S
Practice Address - Street 2:SUITE 110
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-2343
Practice Address - Country:US
Practice Address - Phone:320-685-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN490132100Medicaid
MN5730240001Medicare NSC
MNU82104Medicare UPIN
MN490132100Medicaid