Healthcare Provider Details

I. General information

NPI: 1720128713
Provider Name (Legal Business Name): LAKE FAMILY VISION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 SOUTH MAIN SUITE C
LAURIE MO
65038-1185
US

IV. Provider business mailing address

PO BOX 1185
LAURIE MO
65038-1185
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-5222
  • Fax: 573-374-7351
Mailing address:
  • Phone: 573-374-5222
  • Fax: 573-374-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberT02682
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02682
License Number StateMO

VIII. Authorized Official

Name: DR. WILLIAM R SCOGGIN
Title or Position: OPTOMETRIST OWNER
Credential: O.D.
Phone: 573-374-5222