Provider Demographics
NPI:1275743304
Name:LIFESTYLE OPTICAL
Entity Type:Organization
Organization Name:LIFESTYLE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:TESTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-567-0707
Mailing Address - Street 1:89 ROYAL PALM PT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4253
Mailing Address - Country:US
Mailing Address - Phone:772-567-0707
Mailing Address - Fax:772-567-5683
Practice Address - Street 1:89 ROYAL PALM PT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4253
Practice Address - Country:US
Practice Address - Phone:772-567-0707
Practice Address - Fax:772-567-5683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1121040001Medicare NSC