Organization
LAKESIDE OPTICAL DISPENSARY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KEVIN CARVO (PRESIDENT)
(509) 765-3497
Entity
Organization
Contact information
Practice address
1020 W IVY AVE, MOSES LAKE, WA 98837-2049
(509) 765-3497
(509) 765-5082
Mailing address
1020 W IVY AVE, MOSES LAKE, WA 98837-2049
(509) 765-3497
(509) 765-5082
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
—
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0016601
L & I
WA
05
—
2521003
—
WA
Enumeration date
04/14/2006
Last updated
08/22/2020
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