MEDICARE: LAKE RIDGE EYE CARE PA

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	6592TG	TX

General Provider Information

NPI Number	:	1558450452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE RIDGE EYE CARE PA

Provider Business Mailing Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	STE. 160
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3073
Country	:	US
Telephone Number	:	972-641-5900
Fax Number	:	972-641-5903

Provider Business Practice Location Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	STE. 160
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3073
Country	:	US
Telephone Number	:	972-641-5900
Fax Number	:	972-641-5903

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CAROLYN KHA
Credential	:	O.D.
Telephone Number	:	972-641-5900

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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