Provider Demographics
NPI:1558450452
Name:LAKE RIDGE EYE CARE PA
Entity Type:Organization
Organization Name:LAKE RIDGE EYE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-641-5900
Mailing Address - Street 1:4927 LAKE RIDGE PKWY
Mailing Address - Street 2:STE. 160
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3073
Mailing Address - Country:US
Mailing Address - Phone:972-641-5900
Mailing Address - Fax:972-641-5903
Practice Address - Street 1:4927 LAKE RIDGE PKWY
Practice Address - Street 2:STE. 160
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3073
Practice Address - Country:US
Practice Address - Phone:972-641-5900
Practice Address - Fax:972-641-5903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6592TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty