Healthcare Provider Details

I. General information

NPI: 1619920576
Provider Name (Legal Business Name): LAKE AND LAKE OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E RUSSELL AVE SUITE A
WARRENSBURG MO
64093-9605
US

IV. Provider business mailing address

601 E RUSSELL AVE SUITE A
WARRENSBURG MO
64093-9605
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2020
  • Fax: 660-747-0574
Mailing address:
  • Phone: 660-747-2020
  • Fax: 660-747-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3409
License Number StateMO

VIII. Authorized Official

Name: DR. JASON S. LAKE
Title or Position: DELEGATED OFFICIAL
Credential: O.D.
Phone: 660-747-2020