Provider Demographics
NPI:1790789550
Name:LAKESIDE VISION INC
Entity Type:Organization
Organization Name:LAKESIDE VISION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-366-7525
Mailing Address - Street 1:888 W HOUGHTON LAKE DR
Mailing Address - Street 2:P O BOX 20
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9451
Mailing Address - Country:US
Mailing Address - Phone:989-366-7525
Mailing Address - Fax:989-366-5405
Practice Address - Street 1:888 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9451
Practice Address - Country:US
Practice Address - Phone:989-366-7525
Practice Address - Fax:989-366-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI2953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1562533Medicaid
MI900G21001OtherBLUE CROSS BLUE SHIELD
MI0159320001Medicare NSC
MI0G26503Medicare PIN
MICG6506Medicare PIN