1619180775 NPI number — LIFETIME EYECARE CENTER LLC

Table of content: (NPI 1619180775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619180775 NPI number — LIFETIME EYECARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME EYECARE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFETIME EYECARE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619180775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5455 MURRELL RD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
VIERA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-6615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-636-1972
Provider Business Mailing Address Fax Number:
321-636-1507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5455 MURRELL RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
VIERA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-6615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-636-1972
Provider Business Practice Location Address Fax Number:
321-636-1507
Provider Enumeration Date:
05/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ROWELL
Authorized Official Title or Position:
OPTOMETRIC PHYSICIAN
Authorized Official Telephone Number:
321-636-1972

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  OPC 1739 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19829 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 078956900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".