Provider Demographics
NPI:1780734418
Name:LAKESHORE VISION CENTERS, LTD
Entity type:Organization
Organization Name:LAKESHORE VISION CENTERS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-487-2020
Mailing Address - Street 1:1021 JEFFERSON ST.
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201
Mailing Address - Country:US
Mailing Address - Phone:920-487-2020
Mailing Address - Fax:920-487-5022
Practice Address - Street 1:1021 JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201
Practice Address - Country:US
Practice Address - Phone:920-487-2020
Practice Address - Fax:920-487-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000047383OtherMEDICARE PTAN
WI0371740002Medicare NSC
CS0632Medicare PIN