Provider Demographics
NPI:1710124573
Name:LAKE VISION OPTOMETRY, INC.
Entity Type:Organization
Organization Name:LAKE VISION OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V. PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:HONG CHAU
Authorized Official - Middle Name:THI
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-244-1122
Mailing Address - Street 1:25321 RAILROAD CANYON RD STE 503
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2702
Mailing Address - Country:US
Mailing Address - Phone:951-244-1122
Mailing Address - Fax:951-244-2777
Practice Address - Street 1:25321 RAILROAD CANYON RD STE 503
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2702
Practice Address - Country:US
Practice Address - Phone:951-244-1122
Practice Address - Fax:951-244-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACC247BMedicare PIN
CA6351960001Medicare NSC