Organization
LAKESIDE VISION INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER BOGGS (OFFICE MANAGER)
(989) 366-7525
Entity
Organization
Contact information
Practice address
888 W HOUGHTON LAKE DR, PRUDENVILLE, MI 48651-9451
(989) 366-7525
(989) 366-5405
Mailing address
888 W HOUGHTON LAKE DR, P O BOX 20, PRUDENVILLE, MI 48651-9451
(989) 366-7525
(989) 366-5405
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
MI2953
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1562533
—
MI
01
—
900G21001
BLUE CROSS BLUE SHIELD
MI
Enumeration date
06/09/2005
Last updated
07/16/2008
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