Provider Demographics
NPI:1760702963
Name:LAKE STREET OPTICAL
Entity Type:Organization
Organization Name:LAKE STREET OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-892-0244
Mailing Address - Street 1:1036 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-2467
Mailing Address - Country:US
Mailing Address - Phone:630-892-0244
Mailing Address - Fax:630-947-0419
Practice Address - Street 1:1036 N LAKE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-2467
Practice Address - Country:US
Practice Address - Phone:630-892-0244
Practice Address - Fax:630-947-0419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04607174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty