Provider Demographics
NPI:1003292954
Name:LAKEFRONT EYE CARE, LLC
Entity type:Organization
Organization Name:LAKEFRONT EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:BERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-578-8055
Mailing Address - Street 1:1931 SHERIDAN BLVD
Mailing Address - Street 2:SUITE S
Mailing Address - City:EDGEWATER
Mailing Address - State:CO
Mailing Address - Zip Code:80214-1316
Mailing Address - Country:US
Mailing Address - Phone:303-508-8055
Mailing Address - Fax:
Practice Address - Street 1:1931 SHERIDAN BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:EDGEWATER
Practice Address - State:CO
Practice Address - Zip Code:80214-1316
Practice Address - Country:US
Practice Address - Phone:303-578-8055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003048152W00000X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010461Medicaid
CO63605376Medicaid
CO3936462Medicare PIN
IL046010461Medicaid