Provider Demographics
NPI:1508953431
Name:LAKE RIDGE VISION CENTER, INC
Entity Type:Organization
Organization Name:LAKE RIDGE VISION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:CONNESS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-680-4323
Mailing Address - Street 1:12444 DILLINGHAM SQ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5258
Mailing Address - Country:US
Mailing Address - Phone:703-680-4323
Mailing Address - Fax:703-680-4358
Practice Address - Street 1:12444 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5258
Practice Address - Country:US
Practice Address - Phone:703-680-4323
Practice Address - Fax:703-680-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02323Medicare PIN