1710168877 NPI number — LIFETIME VISION SOURCE OF LEBANON LLC

Table of content: (NPI 1710168877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710168877 NPI number — LIFETIME VISION SOURCE OF LEBANON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME VISION SOURCE OF LEBANON 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:
Provider Other Organization Name Type Code:
6
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:
1710168877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 MARKET ST
Provider Second Line Business Mailing Address:
STE 20
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97355-2394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-451-1144
Provider Business Mailing Address Fax Number:
541-451-1785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 MARKET ST
Provider Second Line Business Practice Location Address:
STE 20
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97355-2394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-451-1144
Provider Business Practice Location Address Fax Number:
541-451-1785
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TURRENTINE
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
541-451-1144

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1400ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 128772 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 232983 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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