MEDICARE: LAKES OPTOMETRY CLINIC PLLC

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	152W00000X	Optometrist	2773	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487682126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES OPTOMETRY CLINIC PLLC

Provider Business Mailing Address
First Line	:	308 5TH AVE S
Second Line	:	SUITE 110
City	:	COLD SPRING
State	:	MN
Zip	:	56320-2343
Country	:	US
Telephone Number	:	320-685-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 5TH AVE S
Second Line	:	SUITE 110
City	:	COLD SPRING
State	:	MN
Zip	:	56320-2343
Country	:	US
Telephone Number	:	320-685-5400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARY JO JANET FEMRITE
Credential	:	OPTOMETRIST
Telephone Number	:	320-685-5400

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	01/08/2015

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