Provider Demographics
NPI:1457757288
Name:LAKE COUNTRY EYE CARE, LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-367-6610
Mailing Address - Street 1:520 HARTBROOK DR STE F
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1402
Mailing Address - Country:US
Mailing Address - Phone:262-367-6610
Mailing Address - Fax:262-367-0964
Practice Address - Street 1:520 HARTBROOK DR STE F
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1402
Practice Address - Country:US
Practice Address - Phone:262-367-6610
Practice Address - Fax:262-367-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2878-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI152WOOOOXMedicaid
WI11533287OtherCAQH
WIU86423Medicare UPIN
WI0000347730Medicare NSC