Provider Demographics
NPI:1720128713
Name:LAKE FAMILY VISION CENTER INC
Entity Type:Organization
Organization Name:LAKE FAMILY VISION CENTER INC
Other - Org Name:FAMILY EYECARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCOGGIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-374-5222
Mailing Address - Street 1:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:LAURIE
Mailing Address - State:MO
Mailing Address - Zip Code:65038-1185
Mailing Address - Country:US
Mailing Address - Phone:573-374-5222
Mailing Address - Fax:573-374-7351
Practice Address - Street 1:138 SOUTH MAIN
Practice Address - Street 2:SUITE C
Practice Address - City:LAURIE
Practice Address - State:MO
Practice Address - Zip Code:65038-1185
Practice Address - Country:US
Practice Address - Phone:573-374-5222
Practice Address - Fax:573-374-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02682152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0323200001OtherCIGNA MEDICARE