Provider Demographics
NPI:1770026643
Name:BECKER OPTOMETRY, PC
Entity Type:Organization
Organization Name:BECKER OPTOMETRY, PC
Other - Org Name:LAKES FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-346-3073
Mailing Address - Street 1:415 34TH ST N
Mailing Address - Street 2:
Mailing Address - City:DILWORTH
Mailing Address - State:MN
Mailing Address - Zip Code:56529-1801
Mailing Address - Country:US
Mailing Address - Phone:218-346-3073
Mailing Address - Fax:218-346-3074
Practice Address - Street 1:222 MARKET DR
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2116
Practice Address - Country:US
Practice Address - Phone:218-346-3073
Practice Address - Fax:218-346-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2951152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC09382Medicare PIN