Provider Demographics
NPI:1811950009
Name:LAKESHORE EYECARE, INC.
Entity type:Organization
Organization Name:LAKESHORE EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BRITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-970-7444
Mailing Address - Street 1:830 PARKWAY AVE STE E
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9343
Mailing Address - Country:US
Mailing Address - Phone:574-970-7444
Mailing Address - Fax:574-970-7453
Practice Address - Street 1:830 PARKWAY AVE STE E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9343
Practice Address - Country:US
Practice Address - Phone:574-970-7444
Practice Address - Fax:574-970-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-09
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003206A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU92995Medicare UPIN
IN211870Medicare PIN