Provider Demographics
NPI:1083819080
Name:PRIMARY EYECARE INC
Entity Type:Organization
Organization Name:PRIMARY EYECARE INC
Other - Org Name:LIFETIME OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-672-1370
Mailing Address - Street 1:10454 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1433
Mailing Address - Country:US
Mailing Address - Phone:208-672-1370
Mailing Address - Fax:208-672-1404
Practice Address - Street 1:10454 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1433
Practice Address - Country:US
Practice Address - Phone:208-672-1370
Practice Address - Fax:208-672-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806071300Medicaid
IDU31021Medicare UPIN
ID15945021Medicare PIN