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General NPI Number Information
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NPI Number | 1881837243
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Entity Type | Organization
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Legal Business Name | LAKESIDE EYECARE
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Dates
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Enumeration Date | 04/15/2009
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Last Update Date | 02/05/2010
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Provider Practice Location Address
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Address Line | 312 N 4TH ST
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2812
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Country | US
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Telephone | 208-676-1422
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Fax | 208-667-7730
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Provider Business Mailing Address
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Address Line | 312 N 4TH ST
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2812
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Country | US
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Telephone | 208-676-1422
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Fax | 208-667-7730
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN LLOYD CALDERWOOD
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Credential | O.D.
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Telephone | 208-676-1422
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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 | ODP-100067
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License Number State | ID
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