Provider Demographics
NPI:1649586371
Name:LORI A. BUTLER, O.D., LLC
Entity Type:Organization
Organization Name:LORI A. BUTLER, O.D., LLC
Other - Org Name:FAIR LAKES EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:571-239-1465
Mailing Address - Street 1:3140 BRADFORD WOOD CT
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-2738
Mailing Address - Country:US
Mailing Address - Phone:571-239-1465
Mailing Address - Fax:703-281-0304
Practice Address - Street 1:3140 BRADFORD WOOD CT
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124
Practice Address - Country:US
Practice Address - Phone:713-391-4655
Practice Address - Fax:703-281-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU-71182Medicare UPIN