Basic Information
| Provider Information | |||||||||
| NPI: | 1053809152 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFETIME EYECARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2073 | ||||||||
| Address2: | |||||||||
| City: | BAYFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811222073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708842020 | ||||||||
| FaxNumber: | 9708842977 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 MILL STREET | ||||||||
| Address2: | |||||||||
| City: | BAYFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708842020 | ||||||||
| FaxNumber: | 9708842977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | MEIER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9708842020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.