Provider Demographics
NPI:1609060664
Name:LIFETIME EYECARE CENTER
Entity Type:Organization
Organization Name:LIFETIME EYECARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-934-6655
Mailing Address - Street 1:40 TREMONT ST STE 52
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-5316
Mailing Address - Country:US
Mailing Address - Phone:781-934-6655
Mailing Address - Fax:
Practice Address - Street 1:40 TREMONT ST STE 52
Practice Address - Street 2:
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-5316
Practice Address - Country:US
Practice Address - Phone:781-934-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty