Healthcare Provider Details

I. General information

NPI: 1285730911
Provider Name (Legal Business Name): LAKESIDE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 W SALE RD BLDG. F, STE. 3
LAKE CHARLES LA
70605-2400
US

IV. Provider business mailing address

1920 W SALE RD BLDG. F, STE. 3
LAKE CHARLES LA
70605-2400
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-3231
  • Fax: 337-439-0185
Mailing address:
  • Phone: 337-433-3231
  • Fax: 337-439-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number015273
License Number StateLA

VIII. Authorized Official

Name: MRS. ELAINE DYER
Title or Position: OFFICE MANAGER
Credential:
Phone: 337-433-3231