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NPI Code Detail

MEDICARE: LAKES VISION, PC

MEDICARE: LAKES VISION, PC
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
1152W00000XOptometrist2434MN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1410003242OTHERMNMEDICARE PTAN

General Provider Information

NPI Number : 1871825364
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKES VISION, PC
Provider Business Mailing Address
First Line : 24226 RIDGEVIEW CIR
Second Line :
City : DETROIT LAKES
State : MN
Zip : 56501-7151
Country : US
Telephone Number : 218-849-4295
Fax Number : 218-847-8453
Provider Business Practice Location Address
First Line : 1583 HIGHWAY 10 W
Second Line :
City : DETROIT LAKES
State : MN
Zip : 56501-2232
Country : US
Telephone Number : 218-847-7245
Fax Number : 218-847-8453
Authorized Official
Title or Position : OPTOMETRIST
Name : CRAIG ALLEN BRATVOLD
Credential : O.D.
Telephone Number : 218-849-4295
Provider Enumeration Date : 02/08/2010
Last Update Date : 02/08/2010

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Directions to “LAKES VISION, PC ” Practice Location

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