1982933107 NPI number — LIFETIME MEDICAL CENTER, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982933107 NPI number — LIFETIME MEDICAL CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME MEDICAL CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982933107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14244 HIGHWAY 515 N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ELLIJAY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-698-5433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14244 HIGHWAY 515 N
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ELLIJAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-698-5433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
LEE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
706-698-5433

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  051241 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202 G701 589 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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