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General NPI Number Information
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NPI Number | 1831356773
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Entity Type | Organization
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Legal Business Name | LAKE OPTOMETRIC VISION PA
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 05/19/2008
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Provider Practice Location Address
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Address Line | 12700 LAKE BLVD
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City | LINDSTROM
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State | MN
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Zip | 55045
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Country | US
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Telephone | 651-257-2419
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Fax | 651-257-2419
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Provider Business Mailing Address
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Address Line | 12700 LAKE BLVD BOX 552
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City | LINDSTROM
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State | MN
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Zip | 55045
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Country | US
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Telephone | 651-257-2419
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Fax | 651-257-2419
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Authorized Official
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Title or Position | OWNER
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Name | DR. VERNON BRUCE LOVDOKKEN
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Credential | OD
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Telephone | 651-257-2419
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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 | 2142
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License Number State | MN
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