MEDICARE: LOST LAKE OPTICAL COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1003434622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOST LAKE OPTICAL COMPANY

Provider Business Mailing Address
First Line	:	5240 SHADY ISLAND CIR
Second Line	:
City	:	MOUND
State	:	MN
Zip	:	55364-9222
Country	:	US
Telephone Number	:	612-670-8887
Fax Number	:	952-474-1933

Provider Business Practice Location Address
First Line	:	5240 SHADY ISLAND CIR
Second Line	:
City	:	MOUND
State	:	MN
Zip	:	55364-9222
Country	:	US
Telephone Number	:	612-670-8887
Fax Number	:	952-474-1933

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAY B. PETERSEN
Credential	:	O.D.
Telephone Number	:	612-670-8887

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	09/04/2020

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Directions to “LOST LAKE OPTICAL COMPANY ” Practice Location

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