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General NPI Number Information
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NPI Number | 1427292143
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Entity Type | Organization
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Legal Business Name | LAKEVILLE FAMILY EYE CARE LLC
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Dates
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Enumeration Date | 04/24/2009
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 17690 KENWOOD TRL
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City | LAKEVILLE
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State | MN
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Zip | 55044-9764
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Country | US
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Telephone | 952-898-9588
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Fax | 952-898-2030
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Provider Business Mailing Address
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Address Line | 17690 KENWOOD TRL
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City | LAKEVILLE
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State | MN
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Zip | 55044-9764
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Country | US
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Telephone | 952-898-9588
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Fax | 952-898-2030
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANDREW JOSEPH MATTSON
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Credential | O.D.
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Telephone | 952-898-9588
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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 | 2823
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License Number State | MN
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