Provider Demographics
NPI:1659123081
Name:LAKESIDE EYECARE LLC
Entity Type:Organization
Organization Name:LAKESIDE EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARREL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-671-5262
Mailing Address - Street 1:17156 S 4102 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-9460
Mailing Address - Country:US
Mailing Address - Phone:918-671-5262
Mailing Address - Fax:
Practice Address - Street 1:485 S ELM ST
Practice Address - Street 2:
Practice Address - City:OOLOGAH
Practice Address - State:OK
Practice Address - Zip Code:74053-3017
Practice Address - Country:US
Practice Address - Phone:918-671-5262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty