Provider Demographics
NPI:1508291626
Name:LIGHTHOUSE OPTICAL INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-352-2916
Mailing Address - Street 1:317 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237
Mailing Address - Country:US
Mailing Address - Phone:701-352-2916
Mailing Address - Fax:
Practice Address - Street 1:317 COOPER AVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237
Practice Address - Country:US
Practice Address - Phone:701-352-2916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty