Provider Demographics
NPI:1871794362
Name:LAKESIDE EYE CLINIC INC
Entity type:Organization
Organization Name:LAKESIDE EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-553-1818
Mailing Address - Street 1:104 S MICHIGAN AVE
Mailing Address - Street 2:410
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5902
Mailing Address - Country:US
Mailing Address - Phone:312-553-1818
Mailing Address - Fax:312-641-5503
Practice Address - Street 1:104 S MICHIGAN AVE
Practice Address - Street 2:410
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5902
Practice Address - Country:US
Practice Address - Phone:312-553-1818
Practice Address - Fax:312-641-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization