Provider Demographics
NPI:1497760854
Name:TRI LAKES MEDICAL AND SURGICAL EYE CLINIC, INC.
Entity Type:Organization
Organization Name:TRI LAKES MEDICAL AND SURGICAL EYE CLINIC, INC.
Other - Org Name:TRI LAKES EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-334-0044
Mailing Address - Street 1:915 STATE HIGHWAY 248
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-8003
Mailing Address - Country:US
Mailing Address - Phone:417-334-0044
Mailing Address - Fax:417-334-0046
Practice Address - Street 1:915 STATE HIGHWAY 248
Practice Address - Street 2:SUITE A
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-8003
Practice Address - Country:US
Practice Address - Phone:417-334-0044
Practice Address - Fax:417-334-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 152WC0802X, 152WP0200X
MOR6C05207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO325133601Medicaid
MO3906240002Medicare NSC
MO990001446Medicare ID - Type Unspecified
MOCN6456Medicare ID - Type UnspecifiedRAILROAD MEDICARE