Healthcare Provider Details

I. General information

NPI: 1609969377
Provider Name (Legal Business Name): LIFETIME VISION CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N. MAYS ST.
ROUND ROCK TX
78664
US

IV. Provider business mailing address

408 N. MAYS ST.
ROUND ROCK TX
78664
US

V. Phone/Fax

Practice location:
  • Phone: 512-244-2003
  • Fax:
Mailing address:
  • Phone: 512-244-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2584T
License Number StateTX

VIII. Authorized Official

Name: MARC GEORGE BERGERON
Title or Position: OWNER
Credential:
Phone: 512-244-2003