Provider Demographics
NPI:1780648824
Name:LAKESIDE OPTICAL DISPENSARY, INC.
Entity type:Organization
Organization Name:LAKESIDE OPTICAL DISPENSARY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-765-3497
Mailing Address - Street 1:1020 W IVY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2049
Mailing Address - Country:US
Mailing Address - Phone:509-765-3497
Mailing Address - Fax:509-765-5082
Practice Address - Street 1:1020 W IVY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2049
Practice Address - Country:US
Practice Address - Phone:509-765-3497
Practice Address - Fax:509-765-5082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0016601OtherL & I
WA2521003Medicaid
WA2521003Medicaid