MEDICARE: LAKESIDE OPTICAL

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	332H00000X	Eyewear Supplier	015273	LA

General Provider Information

NPI Number	:	1285730911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE OPTICAL

Provider Business Mailing Address
First Line	:	1920 W SALE RD
Second Line	:	BLDG. F, STE. 3
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2400
Country	:	US
Telephone Number	:	337-433-3231
Fax Number	:	337-439-0185

Provider Business Practice Location Address
First Line	:	1920 W SALE RD
Second Line	:	BLDG. F, STE. 3
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2400
Country	:	US
Telephone Number	:	337-433-3231
Fax Number	:	337-439-0185

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ELAINE DYER
Credential	:
Telephone Number	:	337-433-3231

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	10/27/2008

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Directions to “LAKESIDE OPTICAL ” Practice Location

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