=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528066651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE REGION EYE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 04/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 30TH AVE W STE 200
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-763-7055
-----------------------------------------------------
Fax | 320-763-2572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 30TH AVE W STE 200
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-763-7055
-----------------------------------------------------
Fax | 320-763-2572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTICIAN
-----------------------------------------------------
Name | DAVID SCHNEIDERHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-763-7055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MN2707
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------