Provider Demographics
NPI:1619347622
Name:LORI KAY EGEBERG
Entity Type:Organization
Organization Name:LORI KAY EGEBERG
Other - Org Name:SIXTH STREET OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:EGEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-692-5600
Mailing Address - Street 1:511 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-1436
Mailing Address - Country:US
Mailing Address - Phone:605-692-5600
Mailing Address - Fax:
Practice Address - Street 1:511 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1436
Practice Address - Country:US
Practice Address - Phone:605-692-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier