MEDICARE: LIFETIME WOMEN'S HEALTH & FITNESS CENTERS P.C.

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	174400000X	Specialist	0101240033	VA

General Provider Information

NPI Number	:	1093068371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME WOMEN'S HEALTH & FITNESS CENTERS P.C.

Provider Business Mailing Address
First Line	:	3575 BRIDGE RD
Second Line	:	SUITE 8 PMB 433
City	:	SUFFOLK
State	:	VA
Zip	:	23435-1800
Country	:	US
Telephone Number	:	757-395-7414
Fax Number	:	757-923-4607

Provider Business Practice Location Address
First Line	:	1037 CHAMPIONS WAY
Second Line	:	SUITE 300
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3764
Country	:	US
Telephone Number	:	757-395-7414
Fax Number	:	757-923-4607

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDWARD ELLISON WING
Credential	:	MD
Telephone Number	:	757-395-7414

Provider Enumeration Date	:	10/24/2012
Last Update Date	:	10/24/2012

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