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General NPI Number Information
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NPI Number | 1629522974
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Entity Type | Organization
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Legal Business Name | LIFETIME VISION, PLC
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Dates
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Enumeration Date | 08/03/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 255 16TH ST SW
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City | SIOUX CENTER
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State | IA
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Zip | 51250-2959
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Country | US
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Telephone | 720-363-3192
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Fax |
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Provider Business Mailing Address
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Address Line | 1626 7TH AVE SE
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City | SIOUX CENTER
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State | IA
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Zip | 51250-1197
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | CHERYL J. BRONNER
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Credential | O.D.
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Telephone | 720-363-3191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 02040
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License Number State | IA
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