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

Organization subpart

No

Name

Dr. Jay B. Petersen, O.D.

Title

Owner

Phone

(612) 670-8887

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Sep 4, 2020.

{
    "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": []
}

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• All providers in Mound, MN
• 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.