Healthcare Provider Details

I. General information

NPI: 1528066651
Provider Name (Legal Business Name): LAKE REGION EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 30TH AVE W STE 200
ALEXANDRIA MN
56308-3426
US

IV. Provider business mailing address

610 30TH AVE W STE 200
ALEXANDRIA MN
56308-3426
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-7055
  • Fax: 320-763-2572
Mailing address:
  • Phone: 320-763-7055
  • Fax: 320-763-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMN2707
License Number StateMN

VIII. Authorized Official

Name: DAVID SCHNEIDERHAN
Title or Position: OWNER/OPTICIAN
Credential:
Phone: 320-763-7055