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General NPI Number Information
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NPI Number | 1659123081
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Entity Type | Organization
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Legal Business Name | LAKESIDE EYECARE LLC
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Dates
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Enumeration Date | 04/01/2024
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Last Update Date | 04/25/2024
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Provider Practice Location Address
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Address Line | 485 S ELM ST
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City | OOLOGAH
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State | OK
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Zip | 74053-3017
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Country | US
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Telephone | 918-671-5262
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Fax |
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Provider Business Mailing Address
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Address Line | 17156 S 4102 RD
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City | CLAREMORE
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State | OK
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Zip | 74017-9460
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Country | US
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Telephone | 918-671-5262
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MONTE HARREL
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Credential | OD
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Telephone | 918-671-5262
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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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