MEDICARE: LAKE TAHOE EYE CARE OPTOMETRY INC

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	COR53	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ75623Z	OTHER		MEDICARE GROUP PROVIDER #

Other Identifiers

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

General Provider Information

NPI Number	:	1831252808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE TAHOE EYE CARE OPTOMETRY INC

Provider Business Mailing Address
First Line	:	2074 LAKE TAHOE BLVD
Second Line	:	SUITE 2
City	:	SO LAKE TAHOE
State	:	CA
Zip	:	96150-6408
Country	:	US
Telephone Number	:	530-541-2030
Fax Number	:	530-541-3947

Provider Business Practice Location Address
First Line	:	2074 LAKE TAHOE BLVD
Second Line	:	SUITE 2
City	:	SO LAKE TAHOE
State	:	CA
Zip	:	96150-6408
Country	:	US
Telephone Number	:	530-541-2030
Fax Number	:	530-541-3947

Authorized Official
Title or Position	:	V PRES SECY
Name	:	MARK M LEHMANN
Credential	:	OD
Telephone Number	:	530-541-2030

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	09/19/2008

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