Provider Demographics
NPI:1639457864
Name:EYEDENTITY PC
Entity Type:Organization
Organization Name:EYEDENTITY PC
Other - Org Name:LIFETIME VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-321-6332
Mailing Address - Street 1:5525 MERLE HAY RD STE 155
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5525 MERLE HAY RD STE 155
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1446
Practice Address - Country:US
Practice Address - Phone:515-321-6332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty