Healthcare Provider Details

I. General information

NPI: 1316107790
Provider Name (Legal Business Name): LIFETIME EYE CARE OF ROCHESTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 10TH LN NW SUITE 2
ROCHESTER MN
55901-7032
US

IV. Provider business mailing address

3632 10TH LN NW SUITE 2
ROCHESTER MN
55901-7032
US

V. Phone/Fax

Practice location:
  • Phone: 507-282-7121
  • Fax:
Mailing address:
  • Phone: 507-282-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2665
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2665
License Number StateMN

VIII. Authorized Official

Name: DR. JEFFREY LEON ANDERSON
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 507-282-7121