Provider Demographics
NPI:1316107790
Name:LIFETIME EYE CARE OF ROCHESTER INC
Entity type:Organization
Organization Name:LIFETIME EYE CARE OF ROCHESTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-282-7121
Mailing Address - Street 1:3632 10TH LN NW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7032
Mailing Address - Country:US
Mailing Address - Phone:507-282-7121
Mailing Address - Fax:
Practice Address - Street 1:3632 10TH LN NW
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7032
Practice Address - Country:US
Practice Address - Phone:507-282-7121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2665332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN09Y97ANOtherBLUE CROSS BLUE SHIELD
MN09Y99LIOtherBLUE CROSS BLUE SHIELD
MN09Y96LIOtherBLUE CROSS BLUE SHIELD
MN09Y98SIOtherBLUE CROSS BLUE SHIELD
MN09Y96LIOtherBLUE CROSS BLUE SHIELD
MN09Y98SIOtherBLUE CROSS BLUE SHIELD
MNU70536Medicare UPIN
MNV11757Medicare UPIN
MN09Y97ANOtherBLUE CROSS BLUE SHIELD