Provider Demographics
NPI:1912052234
Name:LIFETIME VISION 20/20
Entity Type:Organization
Organization Name:LIFETIME VISION 20/20
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-252-2020
Mailing Address - Street 1:300 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:701-252-2020
Mailing Address - Fax:701-251-2801
Practice Address - Street 1:300 2ND AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3373
Practice Address - Country:US
Practice Address - Phone:701-252-2020
Practice Address - Fax:701-251-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND486152W00000X
ND502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60038Medicaid
ND0255160001Medicare NSC
NDN7104Medicare PIN