MEDICARE: DR. AUDREY LAKE HOUSE O.D.

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	1260	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	093HT	OTHER	NC	BCBS
2	05415	OTHER	NC	SPECTERA
3	28916	OTHER	NC	COMMUNITY EYE CARE

General Provider Information

NPI Number	:	1568518116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY LAKE HOUSE O.D.

Provider Business Mailing Address
First Line	:	7745 BALLANTYNE COMMONS PKWY
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2442
Country	:	US
Telephone Number	:	704-841-3937
Fax Number	:	704-841-3964

Provider Business Practice Location Address
First Line	:	7745 BALLANTYNE COMMONS PKWY
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2442
Country	:	US
Telephone Number	:	704-841-3937
Fax Number	:	704-841-3964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	02/06/2009

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Directions to “ DR. AUDREY LAKE HOUSE O.D.” Practice Location

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