Provider Demographics
NPI:1508902164
Name:LAKES REGION OPTICIANS INC
Entity Type:Organization
Organization Name:LAKES REGION OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:DISPENSING OPTICIAN
Authorized Official - Phone:603-569-5442
Mailing Address - Street 1:PO BOX 1750
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-1750
Mailing Address - Country:US
Mailing Address - Phone:603-569-5442
Mailing Address - Fax:603-569-4378
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:MEDICAL ARTS CENTER
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4411
Practice Address - Country:US
Practice Address - Phone:603-569-5442
Practice Address - Fax:603-569-4378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010616Medicaid
NH30010616Medicaid