Provider Demographics
NPI:1073886412
Name:LIFETIME VISION CARE LLC
Entity Type:Organization
Organization Name:LIFETIME VISION CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-382-3242
Mailing Address - Street 1:901 NW CARLON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2636
Mailing Address - Country:US
Mailing Address - Phone:541-382-3242
Mailing Address - Fax:541-317-3579
Practice Address - Street 1:901 NW CARLON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2636
Practice Address - Country:US
Practice Address - Phone:541-382-3242
Practice Address - Fax:541-317-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty