Provider Demographics
NPI:1215034699
Name:LIFETIME VISION CENTER
Entity Type:Organization
Organization Name:LIFETIME VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-633-1174
Mailing Address - Street 1:330 DILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-3260
Mailing Address - Country:US
Mailing Address - Phone:870-633-1174
Mailing Address - Fax:870-633-3838
Practice Address - Street 1:330 DILLARD AVE
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3260
Practice Address - Country:US
Practice Address - Phone:870-633-1174
Practice Address - Fax:870-633-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106007722Medicaid
AR0160370002Medicare NSC
AR5B443Medicare ID - Type Unspecified