Provider Demographics
NPI:1295972818
Name:LAKE CITY OPTICAL CO INC
Entity type:Organization
Organization Name:LAKE CITY OPTICAL CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/G.M.
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:FLATER
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:352-332-3937
Mailing Address - Street 1:1132 NW 76TH BLVD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6749
Mailing Address - Country:US
Mailing Address - Phone:352-332-3937
Mailing Address - Fax:352-332-0435
Practice Address - Street 1:295 NW COMMONS LOOP
Practice Address - Street 2:#105
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-7709
Practice Address - Country:US
Practice Address - Phone:386-752-3733
Practice Address - Fax:386-755-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0873340001Medicare NSC