MEDICARE: LIFETIME VISION SOURCE OF LEBANON LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1400ATI	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710168877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME VISION SOURCE OF LEBANON LLC

Provider Business Mailing Address
First Line	:	90 MARKET ST
Second Line	:	STE 20
City	:	LEBANON
State	:	OR
Zip	:	97355-2394
Country	:	US
Telephone Number	:	541-451-1144
Fax Number	:	541-451-1785

Provider Business Practice Location Address
First Line	:	90 MARKET ST
Second Line	:	STE 20
City	:	LEBANON
State	:	OR
Zip	:	97355-2394
Country	:	US
Telephone Number	:	541-451-1144
Fax Number	:	541-451-1785

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	TERESA TURRENTINE
Credential	:
Telephone Number	:	541-451-1144

Provider Enumeration Date	:	11/16/2007
Last Update Date	:	12/02/2008

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Directions to “LIFETIME VISION SOURCE OF LEBANON LLC ” Practice Location

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