1265840037 NPI number — LIFETIME MEDICAL CARE PLLC

Table of content: (NPI 1265840037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265840037 NPI number — LIFETIME MEDICAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME MEDICAL CARE PLLC
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:
1265840037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 CLEARWATER DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86305-7180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-237-9014
Provider Business Mailing Address Fax Number:
928-237-9063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 CLEARWATER DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-7180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-237-9014
Provider Business Practice Location Address Fax Number:
928-237-9063
Provider Enumeration Date:
07/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DAMSCHRODER
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/OWNER/PROVIDER
Authorized Official Telephone Number:
928-237-9014

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  AP7289 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AP7289 . This is a "NURSE PRACTITIONER LICENSE NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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