Provider Demographics
NPI:1568518116
Name:HOUSE, AUDREY LAKE (OD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:LAKE
Last Name:HOUSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7745 BALLANTYNE COMMONS PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2442
Mailing Address - Country:US
Mailing Address - Phone:704-841-3937
Mailing Address - Fax:704-841-3964
Practice Address - Street 1:7745 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2442
Practice Address - Country:US
Practice Address - Phone:704-841-3937
Practice Address - Fax:704-841-3964
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093HTOtherBCBS
NC05415OtherSPECTERA
NC28916OtherCOMMUNITY EYE CARE
NCU02333Medicare UPIN
NC093HTOtherBCBS