Healthcare Provider Details

I. General information

NPI: 1508953431
Provider Name (Legal Business Name): LAKE RIDGE VISION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12444 DILLINGHAM SQ
WOODBRIDGE VA
22192-5258
US

IV. Provider business mailing address

12444 DILLINGHAM SQ
WOODBRIDGE VA
22192-5258
US

V. Phone/Fax

Practice location:
  • Phone: 703-680-4323
  • Fax: 703-680-4358
Mailing address:
  • Phone: 703-680-4323
  • Fax: 703-680-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANE MARY CONNESS
Title or Position: GENERAL PARTNER
Credential: O.D.
Phone: 703-680-4323