Provider Demographics
NPI:1609969377
Name:LIFETIME VISION CARE PA
Entity Type:Organization
Organization Name:LIFETIME VISION CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-244-2003
Mailing Address - Street 1:408 N. MAYS ST.
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664
Mailing Address - Country:US
Mailing Address - Phone:512-244-2003
Mailing Address - Fax:
Practice Address - Street 1:408 N. MAYS ST.
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-244-2003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2584T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty