# LAKESIDE OPTICAL DISPENSARY, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780648824
- **Authorized official:** MR. KEVIN CARVO (PRESIDENT)
- **Authorized official phone:** (509) 765-3497

## Contact information

- **Practice address:** 1020 W IVY AVE, MOSES LAKE, WA 98837-2049
- **Practice address phone:** (509) 765-3497
- **Practice address fax:** (509) 765-5082
- **Mailing address:** 1020 W IVY AVE, MOSES LAKE, WA 98837-2049
- **Mailing address phone:** (509) 765-3497
- **Mailing address fax:** (509) 765-5082

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 156FX1800X | Optician | — | WA | Yes |

## Other

- **Enumeration date:** 04/14/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0016601 | L & I | WA |
| 05 | — | 2521003 | — | WA |