Healthcare Provider Details

I. General information

NPI: 1932419363
Provider Name (Legal Business Name): LIFETIME HEALTH TR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E CAREFREE HWY STE 484
PHOENIX AZ
85085-8839
US

IV. Provider business mailing address

515 E CAREFREE HWY STE 484
PHOENIX AZ
85085-8839
US

V. Phone/Fax

Practice location:
  • Phone: 623-521-2930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number00114
License Number StateAZ

VIII. Authorized Official

Name: PROF. CK KLINE
Title or Position: MGR
Credential:
Phone: 623-521-2930