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General NPI Number Information
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NPI Number | 1629741707
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Entity Type | Organization
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Legal Business Name | LIFESTYLE EYE CARE PLLC
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Dates
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Enumeration Date | 07/26/2021
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Last Update Date | 07/26/2021
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Provider Practice Location Address
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Address Line | 1296 UNION UNIVERSITY DR STE B
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City | JACKSON
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State | TN
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Zip | 38305-3714
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Country | US
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Telephone | 731-513-5755
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Fax |
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Provider Business Mailing Address
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Address Line | 1296 UNION UNIVERSITY DR STE B
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City | JACKSON
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State | TN
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Zip | 38305-3714
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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 | OD/OWNER
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Name | TRENT MARTIN
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Credential |
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Telephone | 731-610-0858
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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 |
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License Number State |
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