Organization
LAKE AVENUE EYECARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN A GOSNELL O.D. (OWNER)
(308) 537-3390
Entity
Organization
Contact information
Practice address
829 LAKE AVE, GOTHENBURG, NE 69138-1943
(308) 537-3390
(308) 537-3391
Mailing address
829 LAKE AVE, GOTHENBURG, NE 69138-1943
(308) 537-3390
(308) 537-3391
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
1166
NE
332H00000X
Eyewear Supplier
Primary
1166
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06754
BLUE CROSS BLUE SHIELDPIN
—
05
—
10024987700
—
NE
01
—
240481
MIDLANDS CHOICE
—
Enumeration date
10/03/2007
Last updated
10/27/2022
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