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General NPI Number Information
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NPI Number | 1699712067
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Entity Type | Organization
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Legal Business Name | LAKESIDE OPTICAL INC
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Dates
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Enumeration Date | 06/02/2006
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Last Update Date | 02/01/2012
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Provider Practice Location Address
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Address Line | 6595 SEMINOLE BLVD
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City | SEMINOLE
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State | FL
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Zip | 33772-6314
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Country | US
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Telephone | 727-398-7500
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Fax | 727-398-4851
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Provider Business Mailing Address
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Address Line | 6595 SEMINOLE BLVD
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City | SEMINOLE
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State | FL
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Zip | 33772-6314
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Country | US
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Telephone | 727-398-7500
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Fax | 727-398-4851
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Authorized Official
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Title or Position | PRESIDENT
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Name | BETHANY KAY ALLEN
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Credential | LDO
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Telephone | 727-398-7500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | OE 0000300
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License Number State | FL
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