Provider Demographics
NPI:1831356773
Name:LAKE OPTOMETRIC VISION PA
Entity type:Organization
Organization Name:LAKE OPTOMETRIC VISION PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:LOVDOKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-257-2419
Mailing Address - Street 1:12700 LAKE BLVD
Mailing Address - Street 2:BOX 552
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045
Mailing Address - Country:US
Mailing Address - Phone:651-257-2419
Mailing Address - Fax:651-257-2419
Practice Address - Street 1:12700 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-2419
Practice Address - Fax:651-257-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59389LOOtherBLUE CROSS BLUE SHIELD
MN628823500Medicaid
MN1861534315OtherHEALTHPARTNERS
MN45964OtherPREFERREDONE
MN2214338OtherMEDICA
MN1861534315OtherHEALTHPARTNERS
T65808Medicare UPIN