Provider Demographics
NPI:1750591962
Name:LIFETIME VISION CENTER, LLC
Entity type:Organization
Organization Name:LIFETIME VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:B
Authorized Official - Last Name:YUNKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-746-6745
Mailing Address - Street 1:2900 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6070
Mailing Address - Country:US
Mailing Address - Phone:701-746-6745
Mailing Address - Fax:701-746-6961
Practice Address - Street 1:2900 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6070
Practice Address - Country:US
Practice Address - Phone:701-746-6745
Practice Address - Fax:701-746-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND569152W00000X
NDND464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND711236Medicare ID - Type Unspecified