Provider Demographics
NPI:1760647408
Name:LAKE DRIVE OPTICIANS
Entity Type:Organization
Organization Name:LAKE DRIVE OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-345-0111
Mailing Address - Street 1:224 S POLLARD ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2530
Mailing Address - Country:US
Mailing Address - Phone:540-345-0111
Mailing Address - Fax:
Practice Address - Street 1:224 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2530
Practice Address - Country:US
Practice Address - Phone:540-345-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101000159332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0130140001Medicare PIN