Lost Lake Optical Company

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

LOST LAKE OPTICAL COMPANY

Practice address

5240 Shady Island Cir
Mound, MN 55364-9222

Phone

(612) 670-8887

Fax

(952) 474-1933

NPI assigned

Jul 9, 2020

Last updated

Sep 4, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jay B. Petersen, O.D.

Title

Owner

Phone

(612) 670-8887

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1594252800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599177600000",
    "number": "1003434622",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5240 SHADY ISLAND CIR",
            "city": "MOUND",
            "state": "MN",
            "postal_code": "553649222",
            "telephone_number": "612-670-8887",
            "fax_number": "952-474-1933"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5240 SHADY ISLAND CIR",
            "city": "MOUND",
            "state": "MN",
            "postal_code": "553649222",
            "telephone_number": "612-670-8887",
            "fax_number": "952-474-1933"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOST LAKE OPTICAL COMPANY",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-07-09",
        "last_updated": "2020-09-04",
        "certification_date": "2020-09-04",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "JAY",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "612-670-8887",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Keystone Chiropractic Health Centre PA
• Reilly Lynn Kroiss, DDS
• Sheila Kruesel
• Debra Karen Kullberg, L.A.M.F.T., M.DIV.
• Robert A Lauer, DDS
• Loving Care by Martha
• Mac Medical Concepts LLC
• Patricia J. Mactaggert, M.A.,L.P.
• Mazen Manla, DDS
• Christopher Markov, MA LAMFT

• Clinic/Center in Mound, MN
• Providers in Mound, MN by specialty
• Clinic/Center in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 4, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.