Organization
LOST LAKE OPTICAL COMPANY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAY B. PETERSEN O.D. (OWNER)
(612) 670-8887
Entity
Organization
Contact information
Practice address
5240 SHADY ISLAND CIR, MOUND, MN 55364-9222
(612) 670-8887
(952) 474-1933
Mailing address
5240 SHADY ISLAND CIR, MOUND, MN 55364-9222
(612) 670-8887
(952) 474-1933
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Enumeration date
07/09/2020
Last updated
09/04/2020
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