Provider Demographics
NPI:1053501585
Name:LIFETIME EYEHEALTH ASSOCIATES PC
Entity Type:Organization
Organization Name:LIFETIME EYEHEALTH ASSOCIATES PC
Other - Org Name:LIFETIME EYEHEALTH ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STADELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-355-3912
Mailing Address - Street 1:1718 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2029
Mailing Address - Country:US
Mailing Address - Phone:563-355-3912
Mailing Address - Fax:563-359-4108
Practice Address - Street 1:1718 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2029
Practice Address - Country:US
Practice Address - Phone:563-355-3912
Practice Address - Fax:563-359-4108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0341710001Medicare NSC
I14125Medicare PIN