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General NPI Number Information
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NPI Number | 1003557133
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Entity Type | Organization
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Legal Business Name | LAKESIDE VISION, PRUDENVILLE, PC
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 888 W HOUGHTON LAKE DR
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City | PRUDENVILLE
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State | MI
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Zip | 48651-9451
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Country | US
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Telephone | 989-366-7525
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Fax | 989-366-5405
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Provider Business Mailing Address
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Address Line | PO BOX 20
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City | PRUDENVILLE
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State | MI
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Zip | 48651-0020
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Country | US
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Telephone | 989-366-7525
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Fax | 989-366-5405
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | KYLE BATES
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Credential | OD
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Telephone | 989-366-7525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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