Healthcare Provider Details

I. General information

NPI: 1871733535
Provider Name (Legal Business Name): LIFETIME VISION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 SUMMIT ST
CELINA OH
45822-1023
US

IV. Provider business mailing address

119 SUMMIT ST
CELINA OH
45822-1023
US

V. Phone/Fax

Practice location:
  • Phone: 419-586-5149
  • Fax: 419-586-3122
Mailing address:
  • Phone: 419-586-5149
  • Fax: 419-586-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number3317
License Number StateOH

VIII. Authorized Official

Name: DR. PAUL W WILKEN
Title or Position: DOCTOR
Credential: O.D.
Phone: 419-586-5149