Provider Demographics
NPI:1679767339
Name:CLEAR LAKE OPTICS CORP
Entity type:Organization
Organization Name:CLEAR LAKE OPTICS CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORTHALS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-424-0780
Mailing Address - Street 1:422 S PIERCE AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2709
Mailing Address - Country:US
Mailing Address - Phone:641-424-0780
Mailing Address - Fax:641-424-2345
Practice Address - Street 1:422 S PIERCE AVE STE 100A
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2709
Practice Address - Country:US
Practice Address - Phone:641-424-0780
Practice Address - Fax:641-424-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADB8928OtherRAILROAD MEDICARE
IA1204016Medicaid
IA35096OtherBLUE CROSS BLUE SHIELD
IA35096OtherBLUE CROSS BLUE SHIELD
IAI12927Medicare PIN
IAU78741Medicare UPIN