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General NPI Number Information
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NPI Number | 1306016407
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Entity Type | Organization
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Legal Business Name | LG OPTICAL ENTERPRISES
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Dates
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Enumeration Date | 03/04/2008
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 952 22ND AVE S
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City | BROOKINGS
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State | SD
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Zip | 57006-2830
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Country | US
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Telephone | 605-692-8262
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Fax | 605-692-9805
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Provider Business Mailing Address
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Address Line | 952 22ND AVE S
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City | BROOKINGS
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State | SD
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Zip | 57006-2830
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Country | US
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Telephone | 605-692-8262
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Fax | 605-692-9805
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Authorized Official
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Title or Position | OWNER
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Name | LYNN GANNON
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Credential |
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Telephone | 605-692-8262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 05001593786886EST001
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License Number State | SD
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