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General NPI Number Information
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NPI Number | 1396932430
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Entity Type | Organization
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Legal Business Name | LAKE AVENUE EYECARE LLC
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Dates
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Enumeration Date | 10/03/2007
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Last Update Date | 10/27/2022
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Provider Practice Location Address
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Address Line | 829 LAKE AVE
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City | GOTHENBURG
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State | NE
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Zip | 69138-1943
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Country | US
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Telephone | 308-537-3390
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Fax | 308-537-3391
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Provider Business Mailing Address
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Address Line | 829 LAKE AVE
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City | GOTHENBURG
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State | NE
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Zip | 69138-1943
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Country | US
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Telephone | 308-537-3390
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Fax | 308-537-3391
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN A GOSNELL
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Credential | O.D.
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Telephone | 308-537-3390
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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 | 1166
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 1166
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License Number State | NE
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