Provider Demographics
NPI:1346362373
Name:LIFETIME EYECARE
Entity Type:Organization
Organization Name:LIFETIME EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-642-4656
Mailing Address - Street 1:1230 NORTH AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-3028
Mailing Address - Country:US
Mailing Address - Phone:605-642-4656
Mailing Address - Fax:
Practice Address - Street 1:1230 NORTH AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3028
Practice Address - Country:US
Practice Address - Phone:605-642-4656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD108152W00000X
SD592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS2989Medicare ID - Type Unspecified
SD0767560001Medicare NSC