Healthcare Provider Details

I. General information

NPI: 1952421091
Provider Name (Legal Business Name): LIFESTYLE VISION CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 W CHURCH ST
LIVINGSTON TX
77351-9043
US

IV. Provider business mailing address

1618 W CHURCH ST
LIVINGSTON TX
77351-9043
US

V. Phone/Fax

Practice location:
  • Phone: 936-327-6379
  • Fax:
Mailing address:
  • Phone: 936-327-6379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN B. MOORE
Title or Position: OWNER
Credential: OD
Phone: 936-327-6379