Provider Demographics
NPI:1952421091
Name:LIFESTYLE VISION CENTER, PLLC
Entity type:Organization
Organization Name:LIFESTYLE VISION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:936-327-6379
Mailing Address - Street 1:1618 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-9043
Mailing Address - Country:US
Mailing Address - Phone:936-327-6379
Mailing Address - Fax:
Practice Address - Street 1:1618 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9043
Practice Address - Country:US
Practice Address - Phone:936-327-6379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12709OtherSPECTERA
TX29FFOtherBLUE CROSS BLUE SHIELD
TX30222OtherOPTICARE
TX560275OtherNATIONAL VISION ADMINISTR
TX47746OtherDAVIS VISION
TXU157848OtherSTERLING
TX0007955602OtherAETNA
TX22728OtherAVESIS
TX930767OtherBLOCK INSURANCE
TX28457OtherMEDICAL EYE SERVICES
TX47746OtherDAVIS VISION
TX0007955602OtherAETNA
TXU157848OtherSTERLING
TX22728OtherAVESIS
TX30222OtherOPTICARE
TX00376WMedicare ID - Type Unspecified