=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700338779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESIDE OPTOMETRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2016
-----------------------------------------------------
Last Update Date | 10/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3461 BROOKSIDE RD STE A-1
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95219-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-451-4305
-----------------------------------------------------
Fax | 209-622-4283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3461 BROOKSIDE RD STE A-1
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95219-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-451-4305
-----------------------------------------------------
Fax | 209-622-4283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHINH T. NGUYEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 209-451-4305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT 12656 TPL
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 11714T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------