Provider Demographics
NPI:1831235472
Name:LAKES REGION OPTICIANS INC
Entity type:Organization
Organization Name:LAKES REGION OPTICIANS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:DISPENSING OPTICIAN
Authorized Official - Phone:603-524-2050
Mailing Address - Street 1:3073 WHITE MOUNTAIN HWY
Mailing Address - Street 2:MEMORIAL HOSPITAL BOX 5001
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-5111
Mailing Address - Country:US
Mailing Address - Phone:603-356-4493
Mailing Address - Fax:603-356-4493
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:MEMORIAL HOSPITAL BOX 5001
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5111
Practice Address - Country:US
Practice Address - Phone:603-356-4493
Practice Address - Fax:603-356-4493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010616Medicaid
NH0339530005Medicare ID - Type UnspecifiedDISPENSING OPTICIAN