Provider Demographics
NPI:1871825364
Name:LAKES VISION, PC
Entity type:Organization
Organization Name:LAKES VISION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRATVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-849-4295
Mailing Address - Street 1:24226 RIDGEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7151
Mailing Address - Country:US
Mailing Address - Phone:218-849-4295
Mailing Address - Fax:218-847-8453
Practice Address - Street 1:1583 HIGHWAY 10 W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2232
Practice Address - Country:US
Practice Address - Phone:218-847-7245
Practice Address - Fax:218-847-8453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2434152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003242OtherMEDICARE PTAN