Provider Demographics
NPI:1619180775
Name:LIFETIME EYECARE CENTER LLC
Entity Type:Organization
Organization Name:LIFETIME EYECARE CENTER LLC
Other - Org Name:LIFETIME EYECARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROWELL
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-636-1972
Mailing Address - Street 1:5455 MURRELL RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6615
Mailing Address - Country:US
Mailing Address - Phone:321-636-1972
Mailing Address - Fax:321-636-1507
Practice Address - Street 1:5455 MURRELL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6615
Practice Address - Country:US
Practice Address - Phone:321-636-1972
Practice Address - Fax:321-636-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1739332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19829OtherBCBS OF FL
FL078956900Medicaid
T85231Medicare UPIN
FL078956900Medicaid
FL5966100001Medicare NSC